UNIVERSITY  OF  CALIFORNIA 

CALIFORNIA  COLLEGE  OF  MEDICINE 

LIBRARY 

AUG  1  5  1972 
IRVINE,  CALIFORNIA  92664 


A    TREATISE 


Off 


DISEASES  OF  THE  BONES. 


BY 


THOMAS  M.  MAKKOE,  M.  D., 

PROFESSOR  OF  SUBSERT  IN  THE   COLLEGE  OF  PHYSICIANS  AND  8TIKGEOKS.   SURGEON  OF  THE 
XEW  TOBK  HOSPITAL.   SURGEON  OP  BKLLKYUE  HOSPTTAL,   STTBGKOX  OF  THE  ROOSE- 
VELT HOSPITAL,  coNsutrnra  SURGEON  OF  THE  MOTTNT  SINAI  HOSPITAL, 
OF  THB  STRANGERS'   HOSPITAL,  OF  THE  STATE  WOMAN'S 
HOSPITAL,  AMD  OF  THE  NUBSEBT  AJO)  CHILD'S 
HOSPITAL,  ETC.,  ETC. 


NEW  YORK: 
D.   APPLETON   &    COMPANY, 

549  &  551  BBOADTTAY. 
1872. 


ENTERED,  according  to  Act  of  Congress,  in  the  year  1872, 

BY  D.  APPLETON   &  CO., 
In  the  Office  of  the  Librarian  of  Congress,  at  Washington. 


DEDICATION. 


TO 

]\fij  colleagues  in  the  SURGICAL  DEPAETMEST  or  THE 
YORK  HOSPITAL,  I  dedicate  this  volume  in  grateful  recog- 
nition of  twenty  years'  professional  association,  illustrated 
by  a  thousand  tokens  of  friendship  and  confidence,  and 
unmarred  by  a  single  cloud  of  estrangement,  unbroken  by 
a  single  hour  of  distrust. 


PREFACE. 


THE  book  which  I  now  offer  to  my  professional  brethren 
contains  the  substance  of  the  lectures  which  I  have  delivered 
during  the  past  twelve  years  at  the  College  of  Physicians 
and  Surgeons  of  this  city.  It  does  not  claim  to  be  a  com- 
plete compendium  of  all  that  is  known  on  the  subjects  of 
which  it  treats;  for  so  much  has  been  learned  in  bone- 
pathology  since  Stanley's  work  was  published,  now  nearly  a 
quarter  of  a  century  ago,  that  I  have  not  had  the  leisure, 
and  certainly  not  the  ability,  to  write  such  a  treatise.  I 
have,  therefore,  in  the  arrangement  of  the  different  parts  of 
my  work,  followed  rather  the  leadings  of  my  own  studies 
and  observations,  dwelling  more  on  those  branches  where  I 
had  seen  and  studied  most,  and  perhaps  too  much  neglect- 
ing others  where  my  own  experience  was  more  barren,  and 
therefore  to  me  less  interesting.  I  have  endeavored,  how- 
ever, to  make  up  the  deficiencies  of  my  own  knowledge  by 
the  free  use  of  the  materials  scattered  so  richly  through  our 
periodical  literature,  which  scattered  leaves  it  is-  the  right 
and  the  duty  of  the  systematic  writer  to  collect  and  to  em- 
body in  any  account  he  may  offer  of  the  state  of  our  science 
at  any  given  period.  In  all  cases  where  I  have  thus  made 
use  of  the  labors  of  others,  I  have  given  credit  in  the  text 
to  the  authors  from  whom  I  have  quoted. 

The  study  of  Diseases  of  the  Bones  has  had  for  me  a 
life-long  interest,  and  my  opportunities  for  its  cultivation 


vi  PREFACE. 

have  been  ample.  I  can  only  regret  now  that  these  excel- 
lent advantages  have  not  been  turned  to  better  account,  and 
that  my  industry  and  perseverance  have  been  so  far  below 
my  privileges.  For  this,  my  apology,  not  my  excuse,  must 
be,  a  life  somewhat  actively  devoted  to  the  practice  of  my 
profession  and  to  its  public  teaching,  leaving  me  less  time 
to  devote  to  scientific  studies,  than  those  studies,  for  their 
successful  prosecution,  imperatively  demand. 

In  illustrating  the  work,  I  have  not  hesitated  to  borrow 
largely  from  my  friends.  By  the  kind  permission  of  the 
publishers,  I  have  availed  myself  of  a  large  number  of  admi- 
rable woodcuts  from  Paget's  work  on  Surgical  Pathology, 
and  from  Billroth's  work  on  the  same  subject,  translated  by 
Hackley.  All  the  original  illustrations,  mainly  taken  from 
specimens  in  the  cabinet  of  the  New  York  Hospital,  were 
made  for  me  by  Mr.  Joseph  Harley,  of  this  city,  and  are,  1 
think,  remarkably  fine  examples  of  his  beautiful  art.  The 
photographs,  on  which  so  much  of  the  success  of  a  woodcut 
depends,  were  made  by  Mr.  O.  G.  Mason,  the  accomplished 
photographer  of  Bellevue  Hospital. 

I  cannot  too  warmly  express  my  thanks  to  my  profes- 
sional friends,  who  have  in  every  possible  way  encouraged 
and  assisted  me  in  my  work.  I  can  only  say  that,  if  there 
be  any  merit  in  the  book,  it  is  largely  the  result  of  their 
kind  and  active  cooperation,  and  that  a  good  share  of  the 
most  valuable  observations  have  been  contributed  by  their 
generous  friendship. 

If  the  reading  of  my  book  should  afford  as  much  profit 
as  the  preparing  of  it  has  given  me  pleasure,  I  shall  have 
reason  to  be  abundantly  satisfied  with  what  I  have  done. 

NEW  YORK,  March  6,  1872. 


CONTENTS, 


PAGE 

INTRODUCTION      .        .        .        .        .        .        .        .        .        .        .  1 

PAKT  I. 

DISEASES    OF  BONE. 

CHAP.  I. — HYPERTROPHY  AND  ATKOPHY  OF  BONE       ....  13 

II. — INFLAMMATION  OF  BONE 19 

III. — SUPPURATION  IN  BONE 27 

IV. — CHEONIO  SINUOUS  ABSCESS  OF  BONE       ....  33 

V. — DIFFUSE  SUPPURATION. — OSTEO-MYELITIS    ....  45 

VI. — EIOKETS 54 

VII. — MOLLITIES   OSSIUM — MALACOSTEON 74 

VIII. — FBAGILITAS  OSSIUM 82 

IX. — TUBERCULAR  DISEASE  OF  BONE 85 

X.— CABIES 94 

XI. — ISTECROSIS                                                                                                    .  119 


PAET  H. 

TUMORS    OF  BONE. 

CHAP.  I. — CARTILAGINOUS  TUMOES 217 

II.— OSSEOUS  TUMORS 238 

III. — FIBEOUS  AND  FIBROID  TUMORS 256 

IV.— MYELOID  TUMORS 276 

V. — PULSATING  TUMOES  OF  BONE 288 

VI. — TUMORS  OF  THE  JAWS  .        .  300 


viii  CONTENTS. 

PART  III. 
MALIGNANT  DISEASES    OF  BONE. 

PACK 

CHAP.  I. — SCERHHUS,  OR  HAED  CANCER  OF  THE  BONES       .        .        .  336 

II. — MEDTTLLA.RY,  OR  SOFT  CANCER  OF  THE  BONES        .        .  340 

III. — EPITHELIAL  CANCER  OF  BONE 360 

IV. — MELANOID  CANCER  IN  BONE 368 

V. — COLLOID  CANCER  OF  BONE 373 

YI. — OSTOID  CANCER 377 

VII. — TREATMENT  OF  MALIGNANT  DISEASE  OF  BONE   .  381 


DISEASES  OF  THE  BONES. 


INTRODUCTION. 

THE  office  of  the  skeleton  in  the  animal  economy  may  be 
said  to  be  threefold,  viz. :  1.  To  afford  that  support  to  the 
softer  tissues  that  is  needful  to  maintain  the  shape  of  the 
individual ;  2.  To  give  the  protection  to  some  of  the  more 
important  organs  which  the  delicacy  of  their  structure  de- 
mands; and,  3.  To  supply  the  necessary  levers  by  which 
locomotion  is  to  be  accomplished.  In  the  lowest  classes  of 
animals,  whose  functions  are  simple  and  few,  and  whose  vital 
activities  are  moderate,  the  skeleton  seems  to  be  designed 
sometimes  for  mere  support,  and  sometimes  mainly  for  pro- 
tection :  in  the  higher  and  more  complex  animal,  where  the 
tissues  are  beginning  to  arrange  themselves  into  distinct  or- 
gans with  specific  functions,  we  need  both  support  and  pro- 
tection ;  while,  in  the  highest  classes,  including  man,  the 
increasing  diversity  of  organs  and  functions  requiring  varied 
and  precise  movements,  we  have  the  skeleton  divided  into 
many  distinct  parts,  articulated  with  one  another  in  such  a 
way  as  to  be  capable  of  an  infinite  variety  of  movements, 
upon  the  strength  and  precision  of  which  the  perfection  of  the 
varied  functions  depends,  while  the  offices  of  support  and  pro- 
tection have  become  secondary  ones,  almost  lost  sight  of  in  the 
more  prominent  and  more  important  relations  of  the  skeleton 
to  locomotion. 

Thus,  the  coral  animal  supports  its  position  on  the  rock  on 
1 


2  DISEASES   OF  THE  BOXES. 

which  it  grows  by  slowly  calcifying  its  oldest  and  deepest 
layers  until  they  become  part  of  the  stony  structure  itself, 
while  its  younger  and  softer  parts  are  sprouting  and  growing, 
to  repeat,  in  their  turn,  the  same  process  of  solidification,  till 
reefs,  and  islands,  and  continents,  are  upreared  by  their  mar- 
vellous multiplication.  Thus,  too,  in  some  of  the  other  of  the 
lowest  zoophytes,  whose  whole  body  is  little  more  than  a  mass 
of  jelly,  and  whose  almost  only  function  is  nutrition  of  the 
simplest  and  most  direct  character,  we  can  only  regard  its 
silicious  or  calcareous  covering  as  bestowed  upon  it  for  pro- 
tection against  the  rude  agencies  to  which,  in  the  ever-moving 
waters  of  the  ocean,  it  is  constantly  exposed,  and  without 
which  protection  even  its  incalculable  fertility  might  not  be 
able  to  save  its  species  from  extinction.  In  the  higher  classes 
of  the  Radiata,  when  distinct  digestive,  respiratory,  and  gen- 
erative systems  begin  to  show  themselves  with  some  definite 
powers  of  locomotion,  we  find  a  framework  which  is  designed 
not  merely  for  protection,  but  evidently  also  for  preserving 
form,  and  for  giving  effectiveness  to  the  limited  movements 
which  the  animal  is  capable  of  making.  In  the  Mollusca,  where 
the  vegetative  or  organic  is  developed  so  greatly  in  excess  of 
the  animal  or  locomotive  system,  we  find  the  shell  serving  the 
purpose  almost  exclusively  of  protection,  neither  support  nor 
locomotion  depending  on  it  in  any  very  marked  degree ;  while 
in  the  Articulata,  which  as  a  class  present  a  preponderating 
development  of  the  locomotive  system,  we  find  their  hard  cal- 
careous or  horny  casing  BO  arranged  as  not  only  to  preserve 
their  perfect  shape,  but  to  give  variety  and  power  to  the  com- 
plicated movements  by  which  they  are  characterized,  and 
upon  which  their  vital  functions  in  a  great  measure  depend. 
In  the  Mammalia,  some  of  the  more  delicate  organs,  as  the 
brain  and  lungs,  require  the  protection  of  a  bony  envelope  like 
the  skull  and  the  thorax  ;  all  parts  require  the  support  neces- 
sary to  maintain  their  shape ;  and  the  same  support  is  neces- 
sary for  the  action  of  the  muscles  on  the  unyielding  levers  sup- 
plied by  the  bones. 

The  mechanical  necessities  of  the  case,  then,  are  threefold : 
1.  Firmness  of  tissue  sufficient  to  afford  the  requisite  support 
and  protection  ;  2.  Mobility  of  one  part  upon  another,  such  as 


INTRODUCTION.  3 

to  permit  the  movements  of  which  the  muscular  system  is  ca- 
pable ;  and  3.  A  power  of  increase  and  change  which  will  adapt 
it  to  the  increasing  size  or  changing  shape  of  the  animal. 
These  mechanical  requirements  are,  in  the  lowest  classes  of 
animals,  easily  answered  by  a  silicious  or  calcareous  covering, 
which  increases  in  extent  as  the  animal  inhabiting  it  increases 
in  dimensions.  This  increase,  however,  it  must  be  noted,  is 
one  merely  of  superaddition  to  the  edges  or  surfaces  of  the 
original  shell,  which,  once  hardened,  is  no  longer  under  the  in- 
fluence of  vital  action  in  any  such  sense  that  it  can  undergo 
any  change  either  in  its  consistence  or  in  its  size.  It  must  be 
evident,  however,  that  such  an  arrangement  can  only  be  effi- 
cient in  the  simplest  shapes  that  animal  life  assumes,  and  that 
the  moment  complexity  of  form  is  assumed,  and  variety  of 
locomotive  action  exhibited,  a  new  element  is  added  to  the 
problem  of  the  skeleton,  and  that  this  new  element  is  the 
power,  not  merely  to  increase,  but  to  change  its  form,  in  obe- 
dience to  the  changes  which  each  part  of  the  more  complex 
animal  is  liable  to  present,  as  each  part  grows  to  a  greater 
size,  and  usually  to  a  greater  power.  Thus,  in  the  cell-like 
protozoa,  already  alluded  to,  we  can  readily  conceive  that  the 
rounded  or  elongated  form,  partly  roofed  in  by  a  rounded  or 
elongated  shell,  may,  as  it  increases  in  size,  be  still  covered  by 
a  simple  increase  of  size  of  its  protecting  case,  and  the  diffi- 
culty is  not  much  increased  in  the  Radiata,  whose  form  is 
merely  a  repetition  of  simple  elements  round  a  common  centre. 
But,  among  the  Articulata,  as  the  Crustacea  and  the  Insecta, 
the  growth  of  the  animal  in  all  the  segments  of  its  body,  and  in 
all  the  complex  subdivisions  of  limbs  and  antennae,  must  be 
accommodated  by  a  provision  for  something  more  than  a 
mere  superaddition  at  the  edges  of  the  original-simple  formed 
shell. 

This  part  of  the  problem  is  differently  solved  in  different 
classes  of  animals.  In  the  gasteropod  Mollusca,  for  example,  it 
is  evaded  rather  than  solved.  As  the  animal  grows  it  leaves 
the  narrow  quarters  of  its  original  dwelling,  and  finds  better 
accommodation  in  the  larger  segment  of  shell  which,  as  it 
grows,  it  adds  to  the  old  homestead,  from  which  it  usually 
shuts  itself  off  by  a  partition-wall,  which  completely  isolates  the 


4  DISEASES  OF  THE  BONES. 

old  chambers  from  the  new.  In  this  way  many  of  our  most 
beautiful  shells  are  produced,  their  form  and  size  depending 
on  the  successive  additions  and  alterations  which  the  increas- 
ing size,  and  often  the  changing  form,  of  the  animal  has  obliged 
it  to  make  to  its  original  construction.  In  the  oyster,  each 
degree  of  growth  of  the  animal  is  provided  for  by  an  entire 
new  layer  of  shell-growth,  which,  being  internal  and  larger  than 
the  preceding  one,  takes  its  place ;  and  thus  we  have  produced 
the  peculiar  lamination  and  the  very  thick,  heavy  shell  by 
which  these  valuable  animals  are  protected. 

In  many  of  the  Crustacea,  some  of  whom,  as  the  crab  and 
the  lobster,  are  entirely  encased  in  a  calcareous  envelope, 
the  difficulty  is  met  by  a  process  of  throwing  off  the  skeleton 
entirely,  and  providing  a  new  and  larger  one,  proportionate  to 
the  increase  in  size  of  the  animal.  A  similar  action  is  ob- 
served in  some  of  the  changes  which  take  place,  during  the 
development  of  several  species  of  the  Insecta.  This  process 
of  the  periodical  shedding  of  the  shell  is  a  very  curious  and 
interesting  one,  and  it  may  enable  us  to  appreciate  somewhat 
better  the  difficulty  of  the  problem  we  are  now  studying,  to 
watch  the  tedious,  difficult,  and  one  would  think  painful  ex- 
ertions which  these  animals  have  to  undergo,  in  order  to  free 
themselves  from  a  covering  which  has  simply  become  too  small 
for  them,  and  has  by  this  clumsy  process  to  be  got  rid  of,  to 
make  way  for  a  larger  one.  The  imperfection,  if  we  may  so 
speak,  of  the  mode  is  still  more  strikingly  shown  by  the  un- 
protected and  helpless  condition  in  which  the  unhappy  animal 
is  left  after  casting  off  its  old  coat,  and  before  the  new  one  is 
firm  enough  to  be  available. 

In  some  of  these  species,  and  also  in  some  of  the  Yertebrata, 
which  have  a  partial  external  skeleton,  another  arrangement 
is  sometimes  found,  by  which  the  growth  of  the  excrementi- 
tious  skeleton  is  provided  for.  It  is  composed  of  numerous 
plates,  fitting  more  or  less  closely  together,  but  separated  from 
one  another  by  a  portion  of  the  foundation  membrane  of  the 
shell,  which  is  not  calcified,  and  which  therefore  allows  a  cer- 
tain degree  of  mobility  among  the  plates.  This  provides,  to 
some  extent,  for  the  increasing  size  of  the  animal,  but  the 
change  is  still  further  accompanied  by  an  actual  increase  in 


INTRODUCTION.  5 

size  of  each  separate  piece,  by  deposition  at  its  edges.  By  this 
method  form  is  maintained,  and  mobility  secured,  without  the 
necessity  of  the  uncomfortable  and  expensive  process  of  shed- 
ding. 

In  the  Yertebrata,  where  great  complexity  of  structure  and 
function  demanded  great  variety  and  precision  of  muscular 
movement,  and  where  the  importance  of  the  life  of  external 
relation  required  something  more  sensitive  than  a  calcareous 
shell,  the  skeleton  becomes  more  complex  in  its  form,  greatly 
multiplied  in  the  number  of  its  pieces,  and  either  mainly  or 
entirely  internal  in  its  position.  And  now  we  find,  in  obe- 
dience to  its  higher  requirements,  that  the  skeleton  is  no  longer 
a  mere  dead,  uechanging,  excrementitious  substance,  entirely 
removed  from  the  actions  of  the  living  organism,  and  incapa- 
ble, except  by  bare  addition1  to  its  mass,  of  changing  with  the 
changing  necessities  of  the  body.  It  has  now  become  a  living 
part  of  a  living  body;  it  is  capable,  by  its  own  nutritive 
capacities,  of  growing  and  changing  with  the  increasing  size 
or  varying  necessities  of  the  part  which  it  supports.  In  short, 
it  is  endowed  with  all  the  powers  of  adaptation  which  the  most 
favored  tissues  possess,  and  exhibits  in  a  high  degree  the  pres- 
ence and  action  of  that  formative  force  and  nutritive  energy 
by  which  the  integrity  of  all  parts  of  the  living  body  tends  to 
be  preserved,  both  under  the  demands  of  health  and  the  press- 
ure of  disease. 

And  here  the  vital  problem  is  superadded  to  the  mechani- 
cal. How  to  endow  with  all  the  attributes  of  life  a  tissue  that 
shall  be  hard  enough,  and  therefore  strong  enough,  to  answer 
the  mechanical  purposes  of  an  internal  skeleton,  was  the  ques- 
tion to  be  answered,  and  most  admirably  has  it  been  solved. 
The  unabsorbing  and  impenetrable  bone-tissue  forbade  the  im- 
bibition of  the  nutritive  juices  into  its  substance,  by  which 
imbibition,  indeed,  the  very  strength  of  the  structure  must 
necessarily  be  compromised,  and  therefore  we  find  its  nutrition 
carried  on  on  a  plan  entirely  peculiar  to  itself.  ~Not  only  are 
the  vessels  introduced  into  every  part  even  of  the  hardest  bone, 
but  its  tissue  is  studded  everywhere  with  minute  centres  of 
cell-life  in  the  form  of  the  bone-corpuscles,  which  are,  in  fact, 
nothing  more  than  bone-spaces  containing  cells.  These  spaces 


6  DISEASES  OF  THE  BONES. 

are  far  too  numerous,  and  much  too  minute,  to  have  any  direct 
relation  to  the  bone-capillaries,  but  they  are  brought  into  such 
relation  by  a  series  of  fine  tubes,  or  canaliculi,  which  permeate 
all  the  interspace  between  the  bone-cells  and  the  capillaries, 
opening  a  communication  between  them,  by  which  the  plasma 
of  the  blood,  exuded  from  its  vessels,  finds  its  way  easily  and 
abundantly  to  the  most  distant  bonercorpuscles,  and  thus  per- 
meates the  bone  to  its  minutest  elemental  particle.  This 
beautiful  and  perfect  system  of  pores,  traversing  all  the  terri- 
tories between  the  Haversian  canal  and  the  bone-corpuscle, 
secures  all  the  advantages  to  the  bone  which  imbibition  gives 
in  the  nutrition  of  the  softer  tissues,  and  yet,  by  the  fineness 
of  its  arrangement,  it  does  not  interfere  with  the  solidity  and 
strength  of  the  hard  and  intractable  substance  for  whose  nu- 
trition it  so  perfectly  provides. 

By  these  peculiar  and  admirable  arrangements  of  its  nu- 
tritive supply,  bone  becomes  endowed  with  a  grade  of  vitality 
equal  to  that  of  the  most  favored  tissues  of  the  body.  It  is 
not  only  a  living  part,  capable  of  growing  with  the  growth  and 
changing  with  the  change  of  the  growing  and  changing  frame, 
but  it  is  endowed  with  all  the  highest  attributes  of  vitality, 
not  only  in  its  power,  first,  of  Growth,  but  second,  of  Develop- 
ment •  third,  of  Regeneration  /  fourth,  of  Repair  y  and,  fifth, 
of  Disease. 

1.  Of  Growth. — The  increase  of  size  of  the  shell  of  the 
oyster  or  of  the  crab  is,  as  we  have  seen,  one  of  mere  super- 
addition  to  parts  already  formed,  and  which  in  themselves  are 
incapable  of  any  other  change.  Bone  grows  by  an  inherent 
vital  power,  by  which  it  accommodates  itself  to  the  increasing 
size  of  the  animal  to  which  it  belongs,  and  this  by  a  series  of 
interstitial  changes  in  its  particles  as  complete  as,  though  prob- 
ably much  less  rapid  than,  those  with  which  we  are  familiar  in 
the  soft  parts.  This  growth,  of  course,  is  mostly  observed  in 
the  younger  and  softer  bone,  which  is  in  the  process  of  attain- 
ing its  final  and  adult  size ;  but  it  is,  nevertheless,  true,  that 
the  process  of  true  interstitial  growth  can  be  demonstrated  on 
the  mature  and  firmly-ossified  bone  of  young  adults ;  and  it  is 
altogether  probable  that,  even  in  the  most  solid  and  mature 


INTRODUCTION.  7 

bones  of  later  life,  the  interstitial  and  molecular  changes,  which 
we  know  to  characterize  the  life  of  the  softer  tissues,  are  the 
constant  conditions  of  the  life  of  the  bone. 

2.  Development. — No  phases   of  development   are  more 
beautiful  or  more  interesting  in  their  study  than  those  of  the 
skeleton  from  its  first  rudimentary  trace  up  to  its  perfect  form. 
None  aiford  better  opportunities   for  observation,  and  none 
better  illustrate  the  laws  which  regulate  the  process.     But, 
besides  this  original  development,  by  which  the  properties  of 
mature  bone  are  assumed,  after  its  passage  through  many  inter- 
mediate, less  perfect,  and  gradually  improving  stages,  we  have 
the  fact  daily  verified  that  the  mature  adult  skeleton  will  de- 
velop itself  not  merely  in  general  robustness,  but  in  the  actual 
increase  of  its  bony  processes,  by  virtue  of  the  law  that  every 
part  grows  in  size  and  strength  by  increased  exercise  of  its 
function.     Exercise  and  labor  will  develop  the  bones  just  in 
the  same  manner,  and  precisely  for  the  same  reason,  that  they 
develop  the  muscles  themselves  ;  and,  moreover,  though  it  may 
be  a  slower  result,  yet,  if  the  increased  exercise  be  maintained 
sufficiently  long,  the  development  of  the  bones  will  be  precisely 
proportioned  to  the  increase  in  size  and  power  of  the  muscles 
which  move  them. 

3.  Regeneration. — M.  Oilier,   of  Lyons,  and   others  who, 
with  him,  have  been  engaged  in  showing  how  large  a  share  the 
periosteum  takes  in  the  formation  of  bone,  have,  in  the  course 
of  their  numerous  experiments,  fully  demonstrated  how  com- 
plete is  the  regenerating  power  of  bone  if  only  care  have  been 
taken  to  leave  the  periosteum  uninjured,  and  that,  under  favor- 
able circumstances,  the  periosteum,  thus  left,  will  generate  a 
new  bone  almost  as  perfect  as  the  one  which  has  been  removed. 
Bat,  still  further,  when  the  whole  bone,  periosteum  included, 
has  been  removed,  a  certain  amount  of  regenerative  power 
remains,  and  instances  are  on  record  where  the  lower  jaw,  the 
clavicle,  the  ulna,  and  several  other  bones,  have  been  removed 
by  operation  in  the  human  subject,  with  the  result  of  a  repro- 
duction, imperfect,  it  is  true,  but,  nevertheless,  a  regeneration 
of  the  removed  bone,  sufficient  to  maintain  in  part  the  shape, 


8  DISEASES  OF  THE  BONES. 

and  in  some  degree  to  supply  the  loss  of  the  original.  Simi- 
lar partial  regenerations  have  been  observed  in  animals  when, 
in  experimental  operations,  entire  bones,  with  their  periosteum, 
have  been  removed. 

4.  Repair. — Each  of  these  processes  of  growth,  develop- 
ment, and  regeneration,  is  abundantly  provided  for  in  the 
skeletons  of  those  lower  animals  to  which  allusion  has  been 
made  in  former  paragraphs.  Of  repair,  however,  in  the  proper 
sense  of  the  term,  they  are  not  capable.  A  fractured  coral 
stem  is  a  hopeless  severance ;  a  crushed  shell,  in  that  portion 
from  which  the  animal  has  retired,  is  an  unchangeable  injury. 
Even  in  that  part  which  it  still  inhabits,  no  proper  repair  of 
the  injury  to  the  shell  takes  place,  though  the  animal  protects 
its  body  from  the  effects  of  exposure  by  forming  a  new  calca- 
reous layer  opposite  the  damaged  spot,  by  which  the  mischief 
is  rather  compensated  for  than  healed.  The  same  is  true  of 
the  Crustacea.  In  a  lobster  whose  claw  had  evidently  been 
broken  by  contact  with  some  sharp,  hard  edge,  I  recently  ob- 
served the  mode  by  which  the  serious  wound  was  closed.  The 
injury  was  evidently  an  old  one,  and  still  remained — a  gash,  as 
it  were,  in  the  upper  edge  of  one  of  the  large  claws,  nearly  an 
inch  in  depth.  ^The  opening  was  thoroughly  and  neatly  closed 
by  calcareous  matter,  which  had  been  deposited  by  the  vascu- 
lar membrane  which  secretes  the  shell,  and  the  injured  part 
was  thus  separated  from  its  old  relations  to  the  surface  of  the 
animal.  No  deposit  was  found  on  the  broken  edges,  but  by 
time,  through  the  attrition  against  the  gravelly  or  stony 
bottoms  in  which  they  live,  the  sharpness  of  the  edge  was 
smoothed  oif  so  perfectly  that  it  was  only  by  examining  some- 
what carefully  that  the  scar  could  be  distinguished  from  that 
left  by  a  proper  healing  of  the  tissue.  In  all  such  cases,  and 
in  similar  instances  among  the  Insecta,  the  absence  of  repair 
does  not  at  all  depend  on  the  want  of  reparative  power  in  the 
animal,  but  simply  on  the  excrementitious  nature  of  the  skele- 
ton, which  is,  in  that  sense,  no  longer  a  living  part  of  the 
body,  and  cannot,  therefore,  in  its  injuries,  profit  by  the  im- 
mense reparative  capacities  of  the  animal.  The  same  animal, 
and  by  a  law  evidently  of  compensation,  which  cannot  repair 


INTRODUCTION.  9 

a  compound  fracture  of  its  shell,  can  reproduce,  it  may  be,  the 
entire  limb,  if  the  injury  happen  to  be  severe  enough  to  tear 
it  from  its  body. 

Contrasted  with  these  imperfect  efforts  in  the  lower  ani- 
mals, we  find  in  the  higher  Mammalia,  and  particularly  in 
man,  that  the  repair  of  injured  bone  is  among  the  most  beauti- 
ful and  perfect  of  all  the  reparative  actions :  1.  Its  most  strik- 
ing feature  is  that  it  is  intrinsic ;  that  is,  it  depends  for  its  per- 
fection on  the  perfect  life  and  high  vital  organization  of  the 
bone-structure  itself.  2.  It  is  reliable.  Under  all  circumstances 
of  age  and  condition,  and  under  all  degrees  of  injury  which  do 
not  compromise  the  life  of  the  injured  part,  it  may  be  so  surely 
counted  on,  that  occasional  failures  excite  our  surprise,  and 
can  in  most  instances  be  explained  by  some  mechanical  inter- 
ference with  the  process,  rather  than  by  any  want  of  inherent 
power  of  repair.  3.  The  repair  is  economical.  Xo  more  ma- 
terial is  employed  than  necessary,  and  this  material  is  so  per- 
fectly transformed  into  bone-tissue,  that  the  microscope  cannot 
distinguish  between  the  old  and  the  new  formation.  4.  The 
repair  is  complete.  Although,  in  the  highest  Yertebrata,  the 
repairing  material  is  thus  carefully  economized,  the  result  of 
the  process  is  that  the  bone  is,  at  the  point  of  injury,  as  strong 
as,  and  usually  stronger  than,  it  was  before,  so  that,  after  the 
healing  process  is  perfected,  a  fracture  would  be  more  likely  to 
occur  at  some  other  point  than  at  the  seat  of  the  perfectly- 
mended  original  break.  Finally,  the  process  is  so  arranged 
that  its  result  is  shapely.  !N"o  deformity  is  left  beyond  what 
is  the  necessary  result  of  the  displacement  of  the  broken  frag- 
ments. The  uniting  medium  is  so  proportioned,  and  so  ar- 
ranged between  the  parts  it  is  intended  to  heal,  that,  after  the 
process  is  completed,  no  superabundance  remains,  and,  if  the 
broken  ends  have  been  maintained  in  perfect  apposition,  so 
shapely  and  so  perfect  is  the  result,  that  it  is  oftentimes  diffi- 
cult to  decide  that  a  bone  has  been  broken,  when  it  is  ex- 
amined long  after  the  injury,  or,  if  the  fact  of  fracture  is 
known,  to  point  out  the  precise  spot  at  which  the  fracture  was 
situated. 

It  is  true  that,  in  some  of  the  Yertebrata  below  man,  the 
union  of  broken  bones  is  accompanied  by  a  superabundance  of 


10  DISEASES   OF  THE  BONES. 

the  ossific  material  of  repair,  and  that  hence  the  union  in  these 
animals  is  accomplished  with  a  deforming  prominence  of  the 
callus  at  the  seat  of  the  fracture.  But  this  apparent  imperfec- 
tion in  the  process  is  so  evidently  in  obedience  to  certain 
mechanical  conditions  of  the  injured  part,  connected  with  the 
impossibility  of  securing  its  absolute  rest,  that  it  should  rather 
be  regarded  as  an  admirable  illustration  of  adaptability  to  cir- 
cumstances of  the  reparative  force,  than  any  impugnment  of 
the  power  and  perfection  of  that  force  itself. 

5.  Disease. — I  have  classed  the  liability  to  disease  as  one 
of  the  evidences  of  the  high  vital  endowments  of  bone-tissue  ; 
and  while  I  am  not  prepared  to  maintain  that  there  is  in  the 
capacity  for  varied  and  serious  disease  any  direct  indication  of 
high  organization,  yet  it  must  be  acknowledged  that,  under 
our  present  dispensation  of  sorrow,  such  liability  is  in  fact  al- 
ways associated  with  those  tissues,  and,  indeed,  with  those 
animals  who  hold  the  highest  place  in  the  scale  of  complex 
organization  and  varied  function.  Comparative  pathology  has 
not  yet  been  studied  so  carefully  as  its  importance  in  illustrat- 
ing human  disease  would  seem  to  warrant,  but  enough  has  been 
learned  to  give  us  some  valuable  hints.  Thus,  as  a  general 
law,  I  think  it  may  be  stated  that  the  reparative  power  in- 
creases as  perfection  and  complexity  of  organization  diminish. 
I  know  that  this  law  is  riot  by  any  means  uniform  in  its  appli- 
cation to  the  different  classes  into  which  we  divide  the  animal 
kingdom,  but,  for  our  present  purpose,  it  is  quite  safe  to  accept 
it  as  a  general  fact  that  reparative  power  increases  as  we  de- 
scend in  the  animal  series,  and  that,  while  in  the  higher  animals 
moderate  injuries  are  often  followed  by  fatal  consequences,  in 
the  Mollusca  and  the  Articulata  we  find  species  in  which  whole 
limbs  may  be  reformed  after  detachment,  and,  in  the  Radiata, 
some  that  can  reproduce  an  entire  and  perfect  body  out  of  each 
of  the  fragments  to  which  accident  or  design  may  have  re- 
duced it.  This  reparative  force,  thus  readily  called  forth  by 
injury,  we  may  be  pretty  sure,  I  think,  is  also  ever  present  as 
an  antagonist  to  disease  ;  and  that,  by  the  ever-present  virtue 
of  this  powerful  controlling  agency,  disease  in  many  of  the 
lowest  animals  is  either  altogether  prevented  or  is  only  allowed 


INTRODUCTION.  11 

to  assume  its  lowest,  simplest,  and  least  dangerous  manifes- 
tations. 

Tims,  I  believe  it  might  be  maintained  that  the  proneness 
to  disease  is  in  an  inverse  ratio  to  the  reparative  power,  and 
that  therefore  the  animals  highest  in  the  scale  are  those  most 
likely  to  show  varieties  of  severe  and  complicated  disorder. 
The  same  principle  seems  to  me  applicable  to  the  relative 
liability  of  the  different  tissues  of  the  same  individual.  Those, 
for  example,  of  the  lowest  class,  enjoying  a  mere  vegetative 
life,  as  tendon,  aponenrosis,  and  cartilage,  we  find  but  rarely 
the  subjects  of  disease,  and,  when  diseased,  their  affections  are 
commonly  of  the  simplest  character.  Disintegration  from  the 
effects  of  inflammation  is  almost  the  only  morbid  process  we 
know  of  in  the  tendon,  and  ulceration  in  its  varied  forms  is  the 
chief  disease  of  cartilage.  It  is  in  the  higher,  more  vascular, 
more  actively  living  tissues,  that  the  most  varied,  the  most 
frequent,  the  most  interesting,  and  in  all  respects  the  most 
important,  morbid  changes  are  observed  to  take  place,  the  care- 
ful study  of  the  minuter  shades  of  which  is  the  difficult  and 
laborious  task  of  the  modern  student  of  pathology. 

Among  these  higher  tissues,  bone,  as  we  have  seen,  holds, 
by  right  of  its  elaborate  vital  provisions,  a  very  high  position, 
and  this  position  it  abundantly  vindicates  by  the  immense 
variety  of  the  shades  of  its  morbid  actions,  as  well  as  the  fre- 
quency and  severity  of  its  diseases.  We  shall  find  no  morbid 
condition  of  the  soft  parts  of  which  a  counterpart  may  not  be 
found  in  the  bones,  and  few  of  the  tissues  present  so  large  and 
varied  a  catalogue  of  diseases  as  this  same  apparently  insensi- 
ble, and,  to  the  careless  eye,  lowly-organized,  bone-substance. 
It  is  liable  to  every  form  of  nutritive  change,  as  in  hypertrophy 
and  atrophy ;  it  is  subject  to  its  own  peculiar  constitutional 
disorders,  as  in  rickets  and  malacosteon.  It  is  prone  to  inflam- 
mation in  all  its  forms,  and  illustrates  most  admirably  its  every 
variety  and  every  grade,  and  at  the  same  time  sympathizes  so 
keenly  with  every  constitutional  taint  that  a  large  chapter  in 
the  history  of  syphilis  and  scrofula  must  be  taken  from  the 
behavior  of  these  poisons  toward  the  bones.  Its  softer  por- 
tions are  invaded  by  caries  and  tubercle,  while  every  part  is 
liable  to  the  insidious  visitation  of  morbid  growths  of  all  forms, 


12  DISEASES  OF  THE   BONES. 

both  benignant  and  cancerous.  In  short,  it  is  a  microcosm  in 
which  the  whole  story  of  disease  is  to  be  traced,  and  yet  which 
presents  many  phases  of  morbid  action,  so  entirely  peculiar  to 
itself  as  to  entitle  its  study  to  be  ranked  among  the  most 
interesting  and  fruitful  provinces  of  the  great  domain  of  Pa- 
thology. 


PART  I. 
DISEASES   OF    B  O  K"  E 


CHAPTER  I. 

HYPERTROPHY   AND   ATROPHY   OF   BONE. 

BONES,  like  the  soft  parts,  are  liable  to  hypertrophy  from 
two  classes  of  causes :  1.  Those  which  are  morbid  in  their 
action  ;  2.  Those  which  are  unconnected  with  any  appreci- 
able diseased  condition.  Of  the  morbid  conditions  of  bone, 
terminating  in  an  increase  of  their  dimensions,  we  shall  have 
very  frequent  occasion  to  speak  hereafter,  and  we  shall  find  it 
to  be  one  of  the  commonest  results  of  long-continued  inflam- 
matory disease  in  all  its  forms  ;  so  much  so,  that  an  expe- 
rienced eye  can  pronounce,  with  much  accuracy,  that  chronic 
inflammation  has  existed  in  a  bone,  from  an  inspection  only 
of  its  enlarged  size — an  enlargement  which,  in  the  hypertrophy 
from  disease,  is  usually  accompanied  with  more  or  less  distor- 
tion and  deformity. 

In  the  cases  of  hypertrophy  of  bone  which  occur  without 
apparent  morbid  cause,  we  find  the  condition  usually  limited 
to  a  single  bone,  as  the  femur  or  the  tibia,  which,  by  its  undue 
growth,  makes  such  a  disproportion  between  the  length  of  the 
limbs  that  serious  lameness  is  sometimes  thus  produced ;  and 
it  is  always  well  for  surgeons  to  take  into  account  the  possi- 
bility of  such  a  condition  in  measuring  the  length  of  the  two 
limbs,  to  clear  up  doubtful  points  of  diagnosis.  Such  embar- 
rassment in  the  study  of  obscure  cases  is  spoken  of  by  several 
authors ;  and  in  the  New  York  Hospital  an  instance  presented 


14 


DISEASES   OF  BONE. 


itself,  where  only  the  history  of  a  previous  elongation  of  the 
femur  explained  a  discrepancy  in  the  symptoms  which  we 
could  not  otherwise  comprehend. 

Mr.  Stanley  speaks  of  several  of  these  cases  of  simple  hy- 
pertrophy where  the  affected  bones  had  be- 
come curved,  and  Mr.  Paget  gives  a  curious 
instance  from  St.  Bartholomew's  Hospital 
Museum,  where,  the  tibia  having  become 
hypertrophied  while  the  fibula  remained 
unchanged,  the  tibia  had  become  curved 
outward  in  order  to  accommodate  its  in- 
crease to  the  unaltered  fibula,  to  which  it 
was  tied  by  its  ligamentous  attachments 
above  and  below.  Fig.  1,  taken  from  Mr. 
Paget's  work  on  "  Surgical  Pathology,"  gives 
a  very  good  idea  of  the  deformity. 

Hypertrophy  of  bone  may,  however,  be 
the  result  of  increase  in  the  duty  which  a 
given  bone  is  called  on  to  perform.  Of  this 
compensatory  hypertrophy  the  best  example 
with  which  I  am  acquainted  is  shown  in  a 
specimen  in  the  museum  of  the  College  of 
Physicians  and  Surgeons.  The  young  lad 
from  whom  it  was  taken  suffered  from  an 
acute  necrosis  of  one  of  his  tibiae,  involv- 
ing almost  the  whole  length  of  the  shaft. 
For  some  reason,  the  reparative  actions  were 
very  imperfect,  and  almost  no  involucrum 
was  formed,  so  that,  when  the  sequestrum 
became  loose  and  was  removed,  no  new  bone  replaced  the  loss  ; 
and,  though  the  wound  healed,  and  he  was  able  to  go  about, 
yet  the  tibia  was  represented,  for  several  inches,  by  a  mere 
fibrous  band,  in  which  but  little  bone-deposit  could  be  de- 
tected, and  which  gave  no  support  whatever  to  the  limb. 
Under  these  circumstances,  he  was  advised  to  use  the  limb  as 
much  as  possible,  which  he  did,  and  gradually  found  that  it 
began  to  be  stronger,  so  that  before  his  death,  which  took 
place  within  two  years  of  the  operation,  he  could  bear  con- 
siderable weight  upon  it.  The  bones  of  both  legs  are  pre- 


Fio.  1.— (From  Paget.) 


HYPERTROPHY  AND    ATROPHY  OF  BONE.  15 

served,  and  show'  the  tibia  of  the  diseased  side  replaced  in  its 
middle  portion  by  a  mere  fibrous  cord,  with  some  nodules  of 
bone  continuous  with  the  sound  bone  above  and  below,  but 
not  fused  together  in  the  middle ;  so  that  the  supporting  power 


FIG.  2. — (From  New  York  Hospital  Museum.) 

of  the  tibia  is  as  completely  abrogated  as  if  it  had  suffered  a 
fracture  which  had  not  united.  The  fibula  of  that  side,  how- 
ever, has  undergone  hypertrophy,  most  marked  opposite  the 
deficiency  in  the  tibia,  and  so  considerable  that,  on  comparing 
it  with  its  fellow  of  the  opposite  side,  it  is  at  least  three  times 
its  superior  in  thickness  and  strength.  A  more  perfect  illus- 
tration of  simple  compensatory  hypertrophy,  and  a  more  beau- 
tiful manifestation  of  the  intelligent  action  of  the  laws  of  nu- 
tritive reparation,  can  hardly  be  found.  (Fig.  2.) 


16  DISEASES   OF  BOXE. 

Another  form  of  hypertrophy  of  bone  is  that  which  affects 
the  bones  of  the  face,  and  is  commonly  spoken  of  as  the  ivory 
exostosis.  It  consists  of  a  very  dense  and  solid  growth,  which 
slowly  involves  the  bones  of  one  side  of  the  face,  more  com- 
monly in  the  neighborhood  of  the  orbit,  and  which  gradually 
converts  them  into  a  tumor  of  great  size,  which  projects  from 
the  surface  of  the  face,  and  which  encroaches  on  the  cavi- 
ties of  the  nose,  eye,  antrum,  and  mouth,  in  such  a  way  as  to 
produce  the  most  serious  and  sometimes  the  most  dangerous 
deformity.  A  large  number  of  cases  of  this  curious  form  of 
hypertrophy  have  been  collected  by  Mr.  Heath,  in  his  admi- 
rable essay  on  the  "  Injuries  and  Diseases  of  the  Jaws."  The 
disease  is  usually  painless  throughout  its  entire  course,  except 
where  it  inflicts  pain  by  its  encroachment,  and  it  is  unaccom- 
panied by  any  evidences  of  inflammatory  action.  It  seems  to 
affect  adults  of  middle  age,  and  is  not  traceable  to  any  injury 
or  connected  with  any  constitutional  taint.  The  progress  of 
the  disease  is  extremely  slow,  and  presents  ordinarily  no  other 
features  but  those  of  simple  increase.  This  form  of  hyper- 
trophy, however,  is  so  much  allied  to  the  tumors  which  affect 
the  bones  of  the  face,  that  its  more  particular  description  may 
be  conveniently  reserved  for  a  future  chapter. 

Atrophy  of  bone  most  commonly  presents  itself  as  the 
consequence  of  long  -  continued  disuse ;  but  several  other 
causes  sometimes  produce  it.  Thus,  Mr.  Curling  has  shown 
that,  in  certain  cases  of  fracture,  where  the  injury  involves  the 
trunk  of  the  nutritious  artery,  the  fragment  of  bone  which  is 
deprived  of  its  vascular  supply  from  that  source  will  some- 
times undergo  a  process  of  atrophy,  and  that  in  this  way  non- 
union is  sometimes  produced.  Atrophy  of  bone  is  likewise 
seen  in  those  cases  of  localized  paralysis  under  which  the 
whole  limb  wastes  away,  and  in  young  children  never  attains 
its  proper  development.  Disuse,  however,  may,  I  think,  be 
said  to  be  by  far  the  most  common  cause  of  atrophy  of  bone ; 
and,  inasmuch  as  a  certain  amount  of  diminished  activity  accom- 
panies the  action  of  all  other  causes,  it  is  difficult  to  prove  that 
any  one  of  them  is  sufficient  to  produce  the  condition  without 
the  assistance  of  some  degree  of  diminished  functional  activity. 

Two  forms  of  atrophy  present  themselves:  one  in  which 


HYPERTROPHY  AND  ATROPHY  OF  BONE.         17 

there  is  simply  a  diminution  in  the  amount  of  bone  mate- 
rial ;  and  one  in  which  there  is  at  the  same  time  an  exces- 
sive development  of  fat.  These  two  forms  correspond  to  the 
two  conditions  of  atrophy  met  with  in  the  soft  parts ;  and, 
while  it  is  not  possible  to  define  precisely  the  circumstances 
under  which  each  occurs,  yet  I  think  it  would  be  correct  to 
say  that,  generally,  the  simple  atrophy  is  best  seen  in  cases 
where  the  change  takes  place  very  gradually,  and  from  simple 
disuse,  while  the  fatty  degeneration  is  most  striking  where  the 
affection  is  somewhat  acute  in  character,  particularly  if  it  be 
associated  with  some  inflammatory  action  about  the  part  dis- 
eased. Thus,  the  most  striking  example  of  simple  atrophy 
that  I  have  seen,  is  in  a  stump  of  a  tibia,  where  the  end  of  the 
limb  below  the  knee  had  not  been  used  for  support  for  many 
years.  Here  the  bone  is  rarefied,  its  cavities  enlarged,  its 
walls  thinned ;  but,  in  other  respects,  it  is  normal.  On  the 
other  hand,  the  most  marked  instance  of  fatty  change  is  in  the 
bones  of  the  leg  of  a  lad  upon  whom  Dr.  Stevens  performed 
exsection  and  wiring  of  the  fragments  of  an  ununited  com- 
pound fracture.  After  giving  the  poor  boy  a  long  and  faithful 
trial,  the  limb  was  amputated.  The  bones  are  small  and  light, 
and  almost  pliable,  but  they  are  so  much  imbued  with  fat  that, 
though  the  specimen  has  been  in  the  cabinet  of  the  New  York 
Hospital  for  about  twenty-five  years,  it  still,  in  warm  weather, 
distils  oil  enough  each  season  to  destroy  the  varnish,  and  run 
down  on  the  stand  upon  which  the  specimen  is  placed. 

The  occurrence  of  atrophy  from  disuse  has  some  important 
practical  relations.  First,  a  bone  in  a  condition  of  progressive 
atrophy  must  be  very  liable  to  undergo  other  changes,  in  obe- 
dience to  mechanical  influences  acting  upon  it.  I  have  now 
under  my  care  a  lady  who  had  rigidity  and  a  vicious  position 
of  abduction  of  the  hip-joint,  following  a  delivery,  accompanied 
by  convulsions.  For  many  months  she  has  not  been  able  to 
use  the  limb,  and,  though  there  is  no  marked  shortening,  yet 
the  trochanter  of  the  affected  side  has  fallen  in  so  much  as  to 
leave  no  doubt  that  interstitial  absorption  of  the  neck  and  head 
of  the  bone  has  taken  place  to  a  very  marked  extent.  Similar 
changes  we  see  in  old  luxations ;  and  in  atrophied  limbs,  where 
unfavorable  positions  have  been  assumed,  we  see  the  bone  be- 
2 


18  DISEASES  OF  BONE. 

coming  absorbed  under  the  influence  of  the  pressure,  or  bent 
by  the  gradual  action  of  the  force  exerted,  to  a  degree  which 
we  would  not  expect  in  sound,  healthy  bone.  But  perhaps  the 
most  important  practical  deduction  from  the  history  of  atrophy 
is  that  which  inculcates  extreme  care  in  manipulations  with 
bones  which  have  long  been  disused.  The  fact  that  disuse  for 
a  few  months,  or  even  for  a  few  weeks,  will  reduce  the  resisting 
power  of  bone,  should  never  be  forgotten,  and  was  impressed 
upon  my  recollection,  in  the  most  emphatic  but  unpleasant 
manner,  by  the  following  case  : 

Patrick  Barry,  aged  forty-two,  was  admitted  to  the  Xew 
York  Hospital,  October  23, 1854,  with  a  dislocation  of  left  femur, 
of  seven  weeks'  standing.  The  symptoms  were  unequivocal,  and 
the  head  of  the  bone  could  be  felt  on  the  dorsum  of  the  ilium. 
The  man  was  of  good  muscular  development,  but  the  limb  was 
flabby  and  wasted  from  inaction.  Attempts  were  made  to  re- 
duce it  by  Reid's  method  of  manipulation,  and,  being  unsuc- 
cessful, were  abandoned  for  the  ordinary  method  of  Sir  Astley 
Cooper.  Extension  was  made  by  pulleys,  and,  while  a  strong 
movement  of  adduction  was  being  made  by  my  own  hand,  a 
crack  was  heard,  and  it  immediately  became  evident  that  the 
neck  of  the  femur  had  broken.  On  taking  off  the  pulleys,  the 
crepitus,  the  form,  and  all  the  symptoms,  made  the  diagnosis 
clear.  In  the  original  minute  of  the  case,  the  remark  is  made  : 
"  With  regard  to  the  fracture  of  the  cervix,  we  were  all  sur- 
prised at  the  slight  amount  of  force  which  was  competent  to 
produce  such  a  mortifying  accident."  A  similar  accident  oc- 
curred to  one  of  my  colleagues  in  attempting  to  reduce  an  old 
dislocation  of  the  elbow-joint.  While  making  extension,  and 
at  the  same  time  trying  to  flex  the  forearm  on  the  arm,  the 
humerus  gave  way,  and  a  very  oblique  fracture  was  found  to 
have  occurred  about  a  hand's  breadth  above  the  joint.  These 
unfortunate  occurrences  (and  most  surgeons  have  had  a  similar 
experience)  should  lead  to  the  greatest  care  in  using  bones, 
which  have  long  been  disused,  as  levers  in  reducing  displace- 
ments, remembering  that  great  power  is  developed  by  the  lever- 
action,  and  that  the  bone-tissue  is  not  so  strong  to  resist  as  it 
is  in  an  unchanged  bone. 


INFLAMMATION  OF  BONE.  19 

CHAPTER  II. 

INFLAMMATION   OF   BONE. 

THE  process  of  inflammation  in  bone  presents  many  modifi- 
cations, due  to  the  peculiar  structure  in  which  it  occurs.  Its 
essential  character  is  the  same,  however,  and  the  laws  which 
govern  it  in  the  soft  parts  are  those  which  regulate  it  in  the 
bones,  due  allowance  being  made  for  the  density  and  intracta- 
bility of  the  tissue  involved.  As  in  the  softer  tissues,  so  in 
the  bones,  we  may  conveniently  arrange  our  study  of  inflam- 
mation into  divisions  embracing  the  various  effects  of  the 
morbid  process,  as  shown  at  each  stage  of  its  progress ;  for, 
while  it  is  well  understood  that  no  absolute  line  separates  one 
stage  from  another,  and  that  one  stage  is  constantly  mingled 
with  another  during  its  progress,  yet,  for  practical  purposes, 
we  shall  recognize  that  each  case  assumes  its  importance  from 
the  prominence  of  one  or  more  features  which  give  it  its  in- 
dividual character,  which  features  are  those  of  some  particular 
stage  or  effect  of  inflammation.  Thus  we  may  include  under 
one  head  all  those  inflammations  of  bone  which  are  attended 
with  organization  of  the  exuded  products.  A  second  class  may 
embrace  those  in  which  the  exudation  goes  on  to  purulent 
formation.  A  third  will  include  all  those  cases  in  which  ul- 
ceration  and  destruction  of  tissue  by  molecular  disintegration 
take  place,  embracing  most  of  the  cases  called  caries ;  and  a 
last  will  embrace  that  large  class  in  which  death  of  tissue  is 
the  consequence  of  the  inflammation,  as  in  necrosis. 

Inflammation  of  Bone  with  Organization  of  the  Inflam- 
matory Products. — The  cases  coming  under  this  head  are, 
almost  uniformly,  of  a  chronic  character,  and  of  a  moderate 
degree.  Their  causes  are  habitual  exposure  to  wet  and  cold, 
injuries  of  moderate  severity,  and  sometimes  a  constitutional 
vice,  either  acquired,  as  syphilis  or  scurvy,  or  original,  as 
scrofula  and  its  numerous  allied  taints  of  the  blood.  Their 
pathological  anatomy  seems  to  be  a  low  grade  of  inflammation 
pervading  a  certain  part  or  the  whole  of  a  bone,  and  which, 


20  DISEASES  OF  BONE. 

after  it  has  been  fully  developed,  presents  microscopical  char- 
acters which  have  now  been  pretty  thoroughly  investigated. 
To  the  unaided  eye,  the  bone  is  of  distinctly  pinkish  or  ruddy 
hue,  usually  in  patches  of  irregular  extent  and  shape,  and  dif- 
fering among  themselves  in  depth  of  color.  The  compact  tissue, 
as  well  as  the  spongy,  shows  this  inflammatory  redness,  though, 
of  course,  in  a  less  degree,  and,  when  thus  reddened  by  inflam- 
mation, has  usually  lost  some  of  its  apparent  density.  The 
periosteum  and  the  medulla  usually  participate,  in  a  marked 
degree,  in  this  vascular  change,  as  they  do  in  all  the  morbid 
actions  of  bone.  Indeed,  writers  are  generally  agreed  that 
they  are  both  of  them  intrinsic  parts  of  bone,  and  that  the  study 
of  their  diseases  cannot  be  and  ought  not  to  be  dissociated 
from  the  diseases  of  the  bone-tissue  itself.  Sometimes,  it  is 
true,  the  inflammatory  actions  are  mainly  confined  to  the 
periosteum,  and  more  rarely  to  the  medulla,  but  the  neighbor- 
ing bone  is  always  more  or  less  implicated,  and  must  necessa- 
rily be  so,  because  its  vessels  are  derived  from,  and  form  part 
of,  the  circulation  of  the  membranes  by  which  it  is  covered. 
After  the  inflammation  has  existed  for  some  time,  the  bone 
begins  to  be  enlarged,  showing  the  addition  of  new  bony  mat- 
ter to  its  original  substance.  This  enlargement  shows  itself  in 
two  principal  ways :  first,  by  increase  of  size,  and,  secondly,  by 
increase  of  density — two  conditions  which,  though  usually 
associated,  are  not  by  any  means  constantly  so ;  and  hence, 
among  the  numerous  specimens  of  inflamed  bone  which  encum- 
ber every  pathological  museum,  we  find  some  which  are  merely 
enlarged,  in  all  their  dimensions,  about  the  seat  of  inflamma- 
tion, without  any  manifest  consolidation  of  tissue,  and  others 
where  the  bulk  has  not  undergone  any  marked  change,  while 
the  increased  weight  and  solidity  show  that  abundant  inter- 
stitial deposit  has  been  taking  place. 

Under  the  microscope  the  first  noticeable  feature  is  the  en- 
largement of  the  Haversian  canals.  This  takes  place  in  obedi- 
ence to  the  requirements  of  the  increasing  vessels,  for  in  a  con- 
dition of  health  the  canal  is  so  nearly  filled  by  the  vessel  which 
traverses  it,  that  little  or  no  enlargement  of  the  latter  can  take 
place  without  some  yielding  of  the  former.  So  true  is  this,  that 
it  is  believed  by  most  pathologists  that  this  impossibility,  in 


INFLAMMATION  OF  BONE.  21 

bone,  of  yielding  to  the  pressure  of  a  suddenly-increasing  cir- 
culation, is  one  principal  reason  why  acute  inflammation  of 
bone  is  so  liable  to  produce  necrosis.  In  more  chronic  and 
moderate  attacks,  there  is  time  afforded  for  the  bony  canals  to 
enlarge  by  absorption,  and  thus  allow  the  gradual  expansion 
of  capillary  vessels  ;  and  hence  there  is  usually  little  or  no  lia- 
bility to  necrosis  where  the  inflammatory  process  assumes  this 
deliberate  and  sometimes  extremely  tedious  course.  Besides 
this  enlargement  of  the  Haversian  canals,  the  lacunae  also 
undergo  a  change  both  in  size  and  shape,  and  the  same  is  ob- 
served in  the  canaliculi.  Mr.  Barwell,  in  his  admirable  ac- 
count of  these  changes,  says :  "  The  lacunae  have  increased  still 
more  in  size  and  breadth ;  even  those  of  the  Haversian  sys- 
tems are  very  broad,  oval,  or  are  rudely  circular  ;  their  interior, 
instead  of  remaining  dark,  has,  as  it  were,  opened  out  into  a 
light  space,  marked  by  light-colored  round  spots,  surrounded 
by  dark  lines,  or  vice  versa^  according  to  the  focus  and  direction 
of  the  light.  Some  of  them  are  very  granular ;  others,  more 
rare,  are  crowded  with  round,  cell-like  bodies,  -forming  a  mul- 
berry mass,  which  appears  to  stand  out  above  the  bone-surface. 
The  canaliculi,  remaining  large  in  number,  have  increased  in 
size  chiefly  at  their  commencement  in  the  lacuna,  so  that  they 
appear  to  open  into  that  space  by  a  broad  mouth  like  an  estu- 
ary. They  are  throughout  more  marked  than  the  normal 
tube ;  they  branch  also  in  many  instances  into  three  or  four 
channels,  and,  sometimes,  at  the  spot  whence  these  branches 
diverge,  a  considerable  enlargement  in  the  main  trunk  is 
perceptible,  as  if  at  that  point  a  new  lacuna  were  being 
formed.  While  these  changes  are  going  on  in  the  lacunae  and 
canaliculi,  a  change  is  also  noticeable  in  the  granular  sub- 
stance of  the  bone-tissue  itself.  The  granular  character 
becomes  more  distinctly  marked,  as  if  a  partial  disintegra- 
tion were  about  to  take  place,  and  the  bone  were  about  to 
break  up  into  its  original  particles.  What  is  the  precise  mean, 
ing  of  this  change,  has  not  been,  so  far  as  I  know,  positively 
determined,  but  Mr.  Follin  does  not  hesitate  to  attribute  the 
general  granular  appearance  of  an  inflamed  bone  to  an  en- 
largement of  the  orifices  of  the  canaliculi,  such  as  has  been 
above  described,  which,  when  the  bone  is  macerated,  gives  a 


22  DISEASES   OF  BONE. 

dotted  or  granular  appearance  of  the  surfaces  on  which  they 
open.  The  further  microscopical  changes  in  inflamed  bone  are 
merely  the  more  advanced  stages  of  what  has  already  been 
described;  the  bone-structure  gradually  disintegrates  and  dis- 
solves away,  and  this  to  an  extent  and  in  a  manner  which 
vary  considerably,  according  to  the  characters  of  the  inflam- 
mation and  the  tendency  which  it  develops.  Consequent,  how- 
ever upon  these  merely  destructive  actions,  we  soon  begin  to 
see  some  attempts  at  reparation,  and,  in  the  moderate  form  of 
inflammation  we  are  now  studying,  these  actions  soon  assume 
the  prominence.  Into  the  natural  cavities  of  the  bone  now 
enlarged  by  the  processes  we  have  been  studying,  we  soon 
have  poured  out  the  plastic  exudations  which  are  the  results 
of  the  inflammation,  and  which  begin  to  show  organization. 
This  organization  leads  by  a  strong  and  almost  unvarying  ten- 
dency to  the  development  into  bone,  so  that  we  soon  begin  to 
find  new  bone  deposited  in  all  the  vacancies  and  porosities  of 
the  old.  By  means  of  these  two  processes,  the  first  one  of  ab- 
sorption, and  the  second  one  of  deposit,  we  have  two  conditions 
of  bone  produced,  which  are  spoken  of  by  writers  as  respectively 
rarefaction  and  condensation  of  bone.  When  in  any  given 
case  the  absorbent  actions  are  in  excess,  and  more  particles 
are  removed  than  are  replaced,  then  we  may  have  an  expan- 
sion with  rarefaction  of  tissue,  or,  as  it  has  been  termed,  osteo- 
porosis. "When,  on  the  other  hand,  the  destruction  is  more 
than  compensated  by  the  deposit  of  new  bone,  then  we  have 
an  expansion  with  consolidation  of  the  inflamed  bone,  so  that 
it  becomes  harder  and  heavier  than  natural.  The  enlargement 
of  bone,  with  expansion  or  rarefaction  of  tissue,  is  the  rarer  of 
the  two,  though  Mr.  Stanley  says,  "  I  have  learned  that  the 
simple  swelling  of  bone,  from  expansion  of  its  tissue,  is  one  of 
the  most  frequent  alterations  to  which  it  is  liable."  We  have,  in 
the  cabinet  of  the  ]STew  York  Hospital,  a  specimen  which  shows 
this  condition  in  a  remarkable  degree.  It  consists  of  the  bones 
of  the  knee-joint  taken  from  a  patient,  a  young  adult,  whose 
limb  was  amputated  for  long-continued  disease  of  the  joint. 
The  whole  bone  is  enlarged,  without  marked  deformity,  but 
every  part  has  undergone  a  sort  of  atrophic  change,  by  which 
the  external  lamina,  the  plates  of  the  cancelli,  indeed  every 


INFLAMMATION  OF  BONE. 


23 


separate  layer  of  bone,  has  become  reduced  down  to  the  thin- 
nest possible  dimensions ;  so  that,  while  every  thing  seems  to  be 
present  that  originally  constituted  the  bone,  yet  it  is  so  refined 
and  so  rarefied  as  to  look  as  if  some  process  of  corrosion  had 
been  adopted  which  had  begun  to  act  upon  the  surfaces  of  the 
bone,  but  had  been  arrested  before  any  lamina  had  been  com- 
pletely destroyed.  The  weight  of  these  bones  cannot  much 
exceed  half  of  what  it  originally  was.  Some  degree  of  this 
expansion  is  very  commonly  seen  in  the  neighborhood  of  caries, 
and  I  suspect  most  often  in  those  cases  which  depend  on  scrof- 
ula. 


FIG.  3.— (From  Billroth.) 


FIG.  4.— <Xew  York  Hospital) 


DISEASES  OF  BONE. 


The  other  condition,  viz.,  enlargement  with  consolidation 
of  tissue,  is  certainly  the  most  frequent  of  all  the  changes  pro- 
duced by  inflammation  in  bone.  It  presents  itself  under  three 
distinct  forms :  1.  Mere  enlargement,  by  which  all  parts  of 
the  bone  seem  to  have  increased  so  equally  that  the  apparent 
structure  is  not  altered,  except  perhaps  by  exaggeration ;  2. 
An  enlargement  in  which  the  tissue  is  condensed  in  such  a 
manner  that  the  original  cavities  of  the  bone  are  encroached 
upon  by  the  new  deposit ;  3.  One  in  which 
the  action  seems  to  be  confined  to  the  peri- 
osteal  surface,  and  where  we  have  some- 
times the  most  abundant  deposits  on  that 
surface,  with  perhaps  little  or  no  change  in 
the  bone  itself.  Fig.  4  is  an  example  of  re- 
markable thickening  and  induration  of  the 
anterior  wall  of  the  tibia,  and  also  of  the 
femur.  The  thickened  portion  is  as  hard 
as  ivory,  which  it  much  resembles  in  ap- 
pearance. This  change  probably  originated 
in  periosteal  inflammation.  Of  these  three 
conditions,  I  think  the  latter  is  the  more  com- 
mon, but  in  all  pathological  collections 
each  of  these  forms  abounds,  sometimes  ex- 
isting separately,  and  very  often  all  com- 
bined in  the  same  specimen  (Fig.  3).  The 
tendency  of  the  periosteum  to  inflammation 
is  recognized  by  all  pathologists ;  and  it  is 
this  inflammation  of  the  periosteum,  rather 
than  of  the  bone  itself,  which  leads  to  the 
formation  of  the  surface-deposits,  which 
often  present  themselves  in  such  abundant 
masses  and  with  such  varied  and  sometimes 
fantastic  shapes  (Fig.  5).  This  affection  is 
one  of  the  forms  of  tertiary  syphilis,  but  it 
is  also  met  with  where  no  such  disease  exists. 
FIG.  5.— (Museum  of  College  It  sometimes  presents  itself  as  one  of  those 

of    Physicians    and    Sur-  /»     T  i  •    t 

geons.)  vague  lorms  ot  disease  which   are  loosely 

classed  as  rheumatism  or  neuralgia.     The  following  is  a  good 
illustration  of  one  of  its  most  common  manifestations.     A  gen- 


INFLAMMATION  OF  BONE.  25 

tleman,  of  about  forty  years,  carne  under  my  care,  many  years 
ago,  for  a  severe  attack  of  neuralgia,  as  he  called  it,  in  one 
of  his  legs.     The  pain  was  seated  along  the  anterior  aspect 
of    the    tibia,    and    was    accompanied    by  great    tenderness 
of  the   bone,  so   much   so   that    he   could   hardly  bear   it   to 
be  touched.     He  was  a  man  ordinarily  in  good  health,  and  at- 
tributed his  attack  to  exposure  to  wet  and  cold,  and  informed 
me  that  several  times  within  a  few  years  he  had  had  similar 
seizures.     The  attack  had  come  on  rather  suddenly  a  few  days 
before  my  seeing  him.     The  pain  was  paroxysmal,  and,  as  he 
described  it,  intolerable,  when  at  its  height.     I  found  some  dif- 
ficulty in  procuring  him  relief,  but  finally  the  attack  subsided, 
and  then  I  discovered,  when  the  tenderness  would  permit  the 
examination,  that  the  tibia  was  enlarged,  apparently  by  a  de- 
posit of  bone  on  its  whole  anterior  surface.     On  pressing  with 
some  firmness,  it  could  be  perceived  that  the  deposit  was  quite 
abundant,  and,  though  distributed  pretty  evenly  over  the  sur- 
face, was  itself  very  irregular  and  rough,  giving  to  the  finger  the 
idea  of  the  skin  being  stretched  over  a  mass  of  coral.     This,  he 
informed  me,  was  the  seat  of  habitual  tenderness,  and  had  been 
for  years  subject  to  occasional  attacks  of  neuralgic  pain  such  as 
above  described.     These  attacks  laid  him  up  for  a  week  or  two, 
and,  for  some  time  after  his  recovery,  walking  was  painful,  and 
in  fact  he  was  gradually  falling  into  a  state  in  which  he  would 
have  to  consider  himself  as  permanently  disabled.     I  attended 
him  in  one  or  two  other  attacks  similar  to  the  one  described,  and 
found  them  becoming  more  frequent  and  severe,  and  leaving 
the  bone  each  time  less  free  from  soreness  and  pain  in  the  in- 
tervals.    I  put  him  on  the  constant  use  of  moderate  doses  of 
the  iodide  of  potassium,  which  seemed  to  have  a  good  effect  in 
relieving  and  diminishing  the  frequency  of  the  attacks,  but  it 
was  not  until  I  had  established  a  nitric-acid  issue,  on  the  upper 
part  of  the  side  of  the  leg,  that  the  paroxysms  gradually  ceased 
altogether.     He  has  worn  this  issue  ever  since,  and,  though  the 
bone-deposit  on  the  tibia  has  undergone  no  material  diminu- 
tion, it  is  no  longer  any  source  of  annoyance  to  him,  and  he 
walks  on  the  diseased  leg  almost  as  well  as  upon  the  other. 
Mr.  Stanley  thinks  that,  when  once  bone  has  become  enlarged, 
no  medicines  have  any  effect  in  reducing  it.     At  the  same  time 


26  DISEASES  OF  BOItE. 

he  is  a  warm  advocate  of  the  efficacy  of  the  iodide  in  reducing 
inflammation  of  bone,  for  which,  indeed,  he  regards  the  remedy 
as  almost  a  specific. 

The  other  conditions  of  enlargement,  in  which  the  bone- 
tissue  itself  is  more  especially  implicated,  may  be  studied  to 
great  advantage  in  the  actions  which  go  on  around  a  seques- 
trum in  an  advanced  case  of  central  necrosis.  There  we  shall 
find,  if  the  case  be  a  recent  one,  and  the  processes  active,  that 
all  the  original  bone,  around  the  central  dead  piece,  takes  on 
an  involucral  action,  and  thickens  and  strengthens,  so  as  to 
compensate  for  the  loss  sustained.  This  condition  may  be  re- 
garded almost  as  a  physiological  one,  in  which  Nature  adopts 
this  method  of  providing  for  the  danger  inflicted  by  the  separa- 
tion of  the  dead  piece.  This  presents  as  good  an  illustration  as 
we  can  have  of  simple  hypertrophy  from  inflammation,  and 
shows  the  bone-tissue  merely  increased  in  quantity,  without 
any  marked  change  in  structure.  If,  however,  these  actions 
are  prolonged  by  the  continued  residence  of  the  sequestrum 
within  the  cavity  of  the  bone,  then  we  have  a  gradual  thicken- 
ing and  condensation  of  the  hitherto  merely  enlarged  involu- 
cral portion,  which  in  old  cases  seems  to  attain  to  the  density 
of  the  hardest  ivory.  Besides  these  cases  of  necrosis,  there  are 
many  others  whose  clinical  history  has  not,  so  far  as  I  know, 
been  very  thoroughly  studied,  where  after  years  of  rheumatic 
and  neuralgic  pain  in  one  or  more  of  the  bones,  perhaps  with 
a  syphilitic  or  scrofulous  taint  of  the  system,  and  a  life  of 
habitual  privation  and  exposure,  we  find  after  death  several  of 
the  bones  presenting  marks  of  inflammation  in  their  increased 
size  and  density,  indicating  processes  which  have  been  going 
on  for  years,  and  yet  without  any  marked  point  in  the  history  at 
which  we  can  say  that  osteitis,  as  a  distinct  affection,  commenced. 

The  treatment  of  chronic  inflammations  of  bone  is  not  very 
satisfactory.  Much  can  be  accomplished,  however,  in  the  ear- 
lier stages,  by  local  bloodletting,  blisters,  and  the  careful  use 
of  mercury,  and,  in  the  later  stages,  by  issues  and  derivatives. 
The  cases,  whose  pathological  anatomy  we  have  been  studying, 
are  apt  to  be  so  vague  and  indistinct  in  their  outlines  during 
life  that  systematic  treatment  for  osteitis  is  generally  either  not 
instituted  at  all,  or  is  so  mingled  with  other  therapeutic  indica- 


SUPPURATION  IN  BONE.  27 

tions  as  to  be  very  much  lost  sight  of  in  summing  up  the  re- 
sults of  the  whole  case.  We  can,  however,  accomplish  much 
in  relieving  the  paroxysms  or  attacks  of  acuter  inflammation  to 
which  these  chronic  cases  are  always  liable,  and,  by  the  iodide  of 
potash,  with  issues  and  counter-irritation,  we  can  so  far  arrest  the 
progress  of  the  inflammatory  actions  that  the  patient  no  longer 
suffers  any  inconvenience  from  his  disease,  except  that  arising 
from  the  weight  or  deformity  of  the  affected  limb.  As  for  the 
influence  of  remedies  on  the  deposits  of  bone  from  inflamma- 
tion, authorities  are  pretty  well  agreed  that  nothing  is  to  be 
expected.  Mr.  Stanley  says :  "  Upon  enlarged  and  indurated 
bone,  medicines  have  no  effect ;  its  condition  will  be  perma- 
nent. .  .  .  But,  against  the  tenderness  and  irritation  of  the  peri- 
osteum, which  precede  and  accompany  the  morbid  changes  in 
the  bones,  treatment  may  be  directed  with  the  best  effect,  par- 
ticularly the  local  application  of  mercury  to  the  limb,  with  the 
administration  of  iodide  of  potassium  and  sarsaparilla." 


CHAPTEE  III. 

SUPPURATION   IN   BOXE. 

As  in  every  other  part  of  the  body,  so  in  bone,  suppuration 
presents  itself  under  two  distinct  forms,  viz. :  1.  Where  the 
action  is  circumscribed,  and  the  pus,  as  it  forms,  is  contained 
in  a  cavity,  and  called  an  abscess ;  and,  2.  Where  the  action  is 
not  circumscribed,  but  spreads  extensively  through  the  affected 
part,  and  the  resultant  pus  is  infiltrated  through  the  substance 
of  the  bone.  These  two  forms  have  so  great  differences  in 
their  pathological  characters,  as  well  as  in  their  clinical  sig- 
nificance, that  they  will  be  conveniently  studied  as  separate 
affections.  And,  first,  for  abscess  of  bone.  Here,  it  will 
be  understood,  that  we  do  not  now  include  in  our  study  those 
various  collections  of  matter  which  form  so  important  a  part  in 
the  pathological  progress  of  caries  and  necrosis.  These  must 
be  considered  hereafter,  and  thus  our  field  is  narrowed  down 
to  the  comparatively  small  number  of  cases  in  which  the  ab- 


28  DISEASES  OF  BOXE. 

scess  character  is  not  only  the  primary  but  the  only  feature  of 
the  disease  throughout  its  whole  course.  Such  abscesses  pre- 
sent themselves  in  three  situations :  1.  In  the  cancellous  struct- 
ure ;  2.  In  the  medulla ;  and,  3.  Between  the  periosteum  and 
the  bone.  As  a  general  fact,  it  may  be  stated  that  all  of  these 
abscesses  are  of  a  chronic  character,  or  perhaps  it  would  be 
more  accurate  to  say,  that  they  are  made  up  of  a  series  of  suc- 
cessive attacks  of  acute  or  subacute  inflammation,  each  of 
which  subsides  to  a  certain  extent,  but,  by  their  constant  recur- 
rence, finally  lead  to  the  formation  of  the  abscess,  and  thus  give 
to  the  whole  case  a  chronic  course,  though  made  up  in  part  of 
acute  elements.  Thus,  to  take  one  case  as  an  example :  Bernard 
Biley,  aged  twenty-one,  was  admitted  to  the  l^ew  York  Hospi- 
tal, June  16,  1857,  with  a  diseased  condition  of  the  lower  half  of 
the  left  tibia,  of  which  he  gave  the  following  history  :  About 
seven  years  previous,  he  had,  without  any  assignable  cause,  a 
sudden  attack  of  acute  inflammation  in  the  upper  part  of  this  leg, 
which  was  attended  with  severe  pain,  rapid  and  considerable 
swelling,  and  suppuration,  which  discharged  itself  on  the  ante- 
rior part  of  the  limb  at  the  end  of  about  three  weeks.  The 
inflammatory  symptoms  subsided,  but  the  abscess  continued 
open  for  about  a  year,  when  a  small  piece  of  bone  came  away, 
and  it  soon  healed  up.  He  had  been  much  reduced  in  health 
by  this  attack,  and  was  not  yet  able  to  walk  about,  when,  as 
the  abscess  above  healed  up,  pain  and  swelling  gradually  came 
on  in  the  lower  part  of  the  leg,  and,  after  nine  weeks,  an  ab- 
scess formed  and  opened,  a  piece  of  bone  came  away,  and  soon 
after  the  sore  healed  soundly.  Several  other  abscesses  formed, 
in  the  same  way,  during  the  next  four  years,  though  they  were 
not  all  accompanied  with  a  discharge  of  bone.  Since  this 
time,  say,  for  the  last  three  years,  he  had  been  improving  in 
health  and  strength,  but  the  lower  half  of  the  tibia  had  been 
the  seat  of  frequent  attacks  of  pain,  lasting  for  a  few  days,  not 
attributable  to  any  particular  cause,  and  usually  relieved  by 
hot  fomentations.  The  tibia  is  now  very  much  enlarged  in  its 
lower  half,  but  there  is  no  evidence  of  any  formation  of  matter, 
and,  during  the  intervals  between  his  attacks  of  pain,  he  is 
able  to  walk  about,  and  to  use  the  limb  freely.  The  pains  are 
always  most  severe  at  night.  There  is  no  suspicion  of  a  syphi- 


SUPPURATION  IN  BONE.  29 

litic  cause.  He  left  Ireland  quite  well  on  the  17th  of  the  pre- 
vious month,  and  on  the  1st  of  April  he  received  a  pretty  hard 
blow  from  a  rope,  across  the  diseased  tibia,  which  produced  a 
very  bad  attack  of  pain,  with  some  swelling,  which,  however, 
soon  subsided,  and,  when  he  landed,  he  was  as  well  as  usual. 
By  walking  about  the  streets  another  attack  was  produced,  and, 
altogether,  he  found  himself  so  much  annoyed  with  these  re- 
peated attacks  of  pain  that  he  became  very  anxious  to  have 
something  done  for  his  relief.  The  lower  half  of  the  tibia  was 
much  enlarged,  very  hard,  slightly  tender  to  the  touch,  and  of 
a  constant  temperature  sensibly  above  that  of  the  surrounding 
parts.  There  was  no  point  more  sensitive  than  the  rest,  nor 
any  evidence  of  matter  seeking  the  surface.  He  says  that  his 
pains,  even  at  their  worst,  are  not  very  severe,  and  it  is  rather 
on  account  of  their  constant  recurrence  that  £hey  have  become 
so  very  distressing  to  him.  From  this  history  of  localized  pain, 
enlargement,  and  increased  heat,  abscess  was  suspected,  and, 
after  he  had  been  in  the  house  a  few  days,  an  operation  was 
performed,  which  it  was  hoped  would  have  a  good  effect  on 
the  chronic  osteitis,  even  if  no  matter  should  be  found.  The 
tibia  was  exposed  on  its  anterior  surface,  and  a  trephine  was 
carried  deeply  into  its  substance,  about  the  middle  of  the  great- 
est enlargement.  When  the  instrument  had  reached  the  centre 
of  the  bone,  pus  began  to  ooze  from  the  saw-cut,  and,  on  re- 
moving the  disk,  we  found  we  had  opened  into  the  cavity  of 
an  abscess,  from  which  two  or  three  drachms  of  pus  flowed  out. 
The  walls  of  the  cavity  were  smooth  and  even,  and  no  dead 
nor  bare  bone  could  be  discovered.  The  wound  was  dressed 
lightly  with  lint.  No  unfavorable  symptom  occurred.  The 
suppuration  gradually  diminished,  the  wound  filled  up  from 
the  bottom  with  healthy  granulations,  and  he  was  discharged 
from  the  hospital,  August  25th,  without  any  return  of  pain, 
and  with  the  wound  almost  entirely  healed.  This  case  is  a  fair 
specimen  of  the  ordinary  form  of  the  disease,  though  some  pa- 
tients suffer  much  more  acute  pain,  and  in  many  the  disease 
is  prolonged  through  a  much  greater  period  of  time.  The  seat 
of  the  affection  is  commonly  the  expanded  articular  extremity 
of  the  bone,  and,  not  unfrequently,  the  abscess  is  situated  so 
near  the  joint  that  its  increase  tends  to  involve  the  joint-cavity, 


30 


DISEASES  OF  BONE. 


and  its  rupture  to  take  place  into  it  (Fig.  6).  Of  tins,  numer- 
ous examples  are  on  record,  and  it  need  hardly  be  said  that 
this  relation  to  the  joint  becomes,  in  such 
instances,  the  important  feature  of  the  case, 
demanding  an  early  recognition  and  a 
prompt  evacuation,  if  any  hope  is  to  be  en- 
tertained of  saving  the  limb,  and,  perhaps, 
the  life  of  the  patient.  The  clinical  fea- 
tures of  this  disease  seem  to  be  mainly 
those  of  chronic  osteitis,  but  characterized 
by  the  frequent  recurrence  of  attacks  of 
pain,  and  other  evidences  of  increased  in- 
flammation, each  of  which  attacks  subsides, 
leaving  the  bone  gradually  enlarging,  some- 
what tender  to  the  touch,  and  a  little  hot- 

Fio.  6._(From  Erichsen.)      ^  than  it  ^^  ^  ^  ^  principal  signg 

of  the  condition  of  chronic  inflammation  which  maintains  itself 
in  the  intervals  between  the  acute  attacks.  The  diagnosis  of 
abscess  cannot  in  all  cases  be  made  with  certainty,  but  with 
such  a  history  of  frequently-recurring  attacks  of  acute  inflam- 
mation, supervening  on  a  condition  of  permanent  osteitis,  we 
shall  rarely  be  wrong  in  suspecting  the  existence  of  pus.  Oc- 
casionally the  pus  makes  its  way  through  its  bony  encasement, 
and  approaches  the  surface,  as  in  the  following  instance : 

Pierce  Doheny,  aged  twenty-four,  was  admitted  into  the 
'New  York  Hospital,  March  28,  1860,  with  an  affection  of  the 
'upper  part  of  the  left  tibia,  of  which  he  gives  this  account : 
"When  he  was  about  nine  years  old,  he  had  an  attack  of  inflam- 
mation in  this  leg,  which  terminated  in  abscess,  with  the  dis- 
charge of  a  small  fragment  of  bone.  This  process  lasted  two 
years  before  the  wounds  were  all  healed,  and  left  the  limb 
tender,  but  without  any  new  attacks,  until  he  was  twenty  years 
old,  when  another  attack  came  on,  which  was  relieved  by  two 
blisters.  This  left  the  bone  considerably  enlarged,  and  more 
tender  than  ever  to  the  slightest  injury.  Three  months  before 
his  admission,  he  had  another  attack  in  the  upper  part  of  the 
bone,  which  had  never  entirely  ceased,  being  better  and  worse 
at  times,  but  on  the  whole  gradually  increasing  in  severity. 
At  the  time  of  admission  the  swelling  occupied  the  upper  third 


SUPPURATION  IN  BONE.  31 

of  the  tibia,  approaching  the  knee-joint — which,  however,  is 
not  involved.  He  suffered  a  good  deal  of  pain,  which  was  so 
aggravated  by  exercise  that  he  was  obliged  to  keep  his  bed. 
There  was  a  general  inflammatory  thickening  of  the  soft  parts, 
but  it  could  easily  be  distinguished  that  a  solid  enlargement 
of  the  bone  made  up  the  bulk  of  the  tumor.  Fluctuation  could 
be  perceived  on  the  central  most  prominent  part  of  the  swell- 
ing. The  limb,  on  measurement,  was  one  inch  longer  than  its 
fellow,  which  was  found  to  be  due  to  hypertrophy  of  the  entire 
tibia,  the  result  doubtless  of  the  long-continued  afflux  of  blood, 
from  the  frequent  inflammatory  attacks  of  which  the  bone  had 
been  the  subject.  His  general  condition  was  good.  The  diag- 
nosis here  was  clear,  and  on  the  17th  of  March  an  operation 
was  performed,  by  raising  the  integuments  by  a  crucial  inci- 
sion and  exposing  the  surface  of  the  enlarged  tibia.  In  doing 
this,  a  small  quantity  of  pus  was  found  between  the  skin  and 
the  bone.  On  wiping  this  pus  off,  it  was  found  to  have  ex- 
uded from  an  irregular  opening  in  the  bone  about  three  lines 
in  diameter,  into  which  a  probe  being  passed  entered  into  a 
considerable  cavity  filled  with  pus.  It  was  an  abscess  in  the 
cancellous  substance  of  the  head  of  the  bone,  which,  having 
perforated  the  external  compact  shell,  was  making  its  way  to 
the  surface.  By  the  chisel  and  trephine,  the  anterior  wall  of 
the  bony  cavity  was  largely  opened.  It  was  found  of  sufficient 
size  to  contain  a  large  hickory-nut,  and  no  sequestrum  could  be 
discovered.  As  there  had  been  no  external  discharge,  its  entire 
independence  of  necrosis  was  demonstrated.  His  recovery  was 
perfect  and  without  accident.  He  was  discharged  from  the 
hospital,  cured,  September  19,  1860. 

The  treatment  of  these  cases  consists  in  a  free  opening  of 
the  abscess,  and,  happily,  it  is  a  treatment  which  is  usually  en- 
tirely successful.  Mr.  Brodie  was  the  first  to  call  attention  to 
these  abscesses  and  to  their  treatment,  and  he  has  published  the 
details  of  seven  cases  in  which  he  established  the  diagnosis  of 
abscess.  All  his  cases  were  in  the  head  of  the  tibia,  and  in  all 
but  the  first  he  had  the  happiness  of  curing  his  patient  by  open- 
ing the  abscess.  In  the  first  case  the  limb  was  amputated,  and 
the  patient  died  ;  and  it  was  by  the  careful  study  of  this  unfor- 
tunate case  that  he  was  led  to  recommend  the  treatment  after- 


32 


DISEASES   OF  BONE. 


ward  adopted,  with  such  satisfactory  results,  in  the  six  success- 
ful cases.  The  operation  consists  in  exposing  the  bone  at  the 
proper  point,  and  introducing  a  small  tre- 
phine, burying  it  deeply  enough  in  the  en- 
larged bone  to  reach  the  matter.  The  se- 
lection of  the  exact  spot  for  making  the 
opening  is  a  point  of  much  moment,  for  a 
few  lines'  deviation  might  lead  to  a  disap- 
pointment in  finding  matter ;  and  Mr.  Bro- 
die  speaks  of  one  such  case  as  occurring 
under  his  observation,  where  "  a  very  ex- 
perienced hospital-surgeon  applied  the  tre- 
phine for  a  supposed  abscess  in  the  head  of 
the  tibia.  No  abscess,  however,  was  dis- 
covered, and  in  consequence  the  limb  was 
amputated.  On  the  parts  being  examined 
afterward,  the  abscess  was  discovered  at  a 
small  distance  from  the  perforation  made  in 
the  operation  ;  and  it  was  plain  that  the 
removal  of  a  small  portion  more  of  the  bone 
would  have  preserved  the  patient's  limb." 
In  such  a  case  it  would  be  proper  to  make 
another  opening,  or  what  is,  I  think,  better, 
to  search  for  the  abscess  by  cutting  away 
the  bone  at  the  bottom  of  the  trephine-cut 
by  a  small  gouge-chisel.  In  this  way  it  can 
rarely  happen  that  matter  will  escape  de- 
tection if  it  really  exists,  accumulated  in  an 
abscess,  though  on  this  point  Mr.  Stanley 
makes  this  very  sensible  remark  :  "  At  the 
same  time  it  must  be  recollected  that  the 
smallest  quantity  of  purulent  fluid  confined 
FIG.  7.-{Xew  York  HOS-  within  a  bone  has  been  the  source  of  very 
severe  suffering  ;  and  that  when  mixed  with 
the  blood,  which  in  general  freely  escapes  from  the  inflamed 
cancellous  texture  around  the  abscess,  the  purulent  fluid  might 
not  be  distinctly  recognized.  The  character  of  the  fluid  escap- 
ing from  the  bone  should  therefore  be  closely  scrutinized."  Fig. 
7,  taken  from  a  specimen  in  the  Xew  York  Hospital  Museum, 


CHRONIC  SINUOUS  ABSCESS   OF  BONE.  33 

shows  the  changes  produced  by  an  old  abscess  in  the  lower  end 
of  the  femur.  The  bone  is  much  thickened,  the  surface  covered 
by  periosteal  growths,  and  an  oblique  opening  on  the  posterior 
part  shows  where  the  abscess  had  discharged  into  the  popliteal 
space. 


CHAPTER  IV. 

CHRONIC   SESTUOU8   ABSCESS   OF   BONE. 

BESIDES  the  cases  of  abscess  of  bone  which  have  been  dis- 
cussed in  the  previous  chapter,  and  which  have  been  so  well 
described  by  Mr.  Brodie,  there  are  a  certain  number  of  others, 
in  which,  with  a  similar  commencement,  a  very  different  prog- 
ress is  observed,  and  in  which  the  diseased  actions,  though 
quite  as  distressing  and  perhaps  more  tedious  and  intractable 
under  ordinary  management,  present  the  features  not  so  much 
of  abscess  as  of  its  eifects ;  not  so  much  the  characters  of  the 
primary  disease  as  of  its  consequences  or  sequelae.  I  refer  to 
cases  in  which  the  inflammation  of  the  bone  begins  as  an  acute 
attack,  passing  rapidly  into  suppuration,  and  in  which  the  ab- 
scess, thus  rapidly  formed,  finds  its  way  early  to  the  surface, 
through  the  compact  external  shell  of  the  bone,  and  is  dis- 
charged, to  the  temporary  relief  of  the  sufferings  of  the  patient, 
though,  it  may  be,  not  greatly  to  his  advancement  toward  a  cure. 
From  this  point  begins  the  marked  difference  in  the  progress  of 
those  cases  which  Mr.  Brodie  describes,  and  those  to  which  I 
wish  now  to  direct  attention.  In  the  former,  the  abscess,  once 
well  open,  goes  on  rapidily  to  a  cure.  In  the  latter,  the  opening 
not  being  free,  and  probably  not  being  direct,  accumulations  of 
matter  take  place  within  the  cavity,  and  new  inflammations  and 
suppurations  are  excited  in  the  bone-substance  surrounding  the 
original  focus  of  disease.  New  abscesses  are  thus  formed, 
which  either  break  into  the  original  cavity,  or  discharge  them- 
selves upon  the  surface  by  forcing  their  way  through  the  com- 
pact outer  layer  of  the  bone.  By  the  repetition  of  this  process 
the  bone  gradually  becomes  the  seat  of  an  inflammatory  hyper- 
trophy, and  the  patient  is  harassed  for  months  by  the  constitu- 
3 


34  DISEASES  OF  BONE. 

tional  disturbance  and  pain  accompanying  these  repeated  sup- 
purations. After  a  time,  varying  in  different  individuals  from 
a  few  weeks  to  many  months,  the  disposition  to  form  new  ab- 
scesses seems  to  cease,  perhaps  because  all  the  cancellous  tissue 
of  the  affected  region  has  become  involved,  either  in  suppura- 
tion or  in  hypertrophic  induration ;  and  the  bone  is  left  per- 
forated in  all  directions  by  two,  three,  four,  or  more  sinuses, 
generally  all  communicating  with  one  another  and  with  a  cen- 
tral excavation  or  chamber,  which  marks  the  position  of  the 
original  abscess.  From  these  openings  is  discharged,  often  in 
considerable  abundance,  a  tliinnish  pus,  sometimes  offensive, 
varying  in  its  quantity  and  quality  with  the  condition  of  the 
patient's  general  health ;  which  discharge,  from  the  shape  and 
position  of  the  channels  through  which  it  comes,  is  indirectly 
and  imperfectly  evacuated,  and  by  its  retention  keeps  up  and 
aggravates  the  chronic  inflammation  which  is  early  set  up  in 
the  surrounding  bone-tissue. 

In  this  state  the  parts  may  continue  without  alteration  for 
an  indefinite  period  of  time,  the  disease  not  showing  much  dis- 
position to  make  encroachments,  but  evidencing  no  tendency 
whatever  toward  improvement.  The  system,  gradually  accom- 
modating itself  to  the  existence  of  the  disorder,  becomes  accus- 
tomed both  to  the  drain  and  the  irritation,  and  the  general 
health  is  often  completely  reestablished.  The  diseased  bone 
becomes  entirely  a  local  affection,  only  troublesome  from  the 
amount  of  pain  and  soreness  experienced — an  amount  which, 
in  different  cases,  varies  from  a  slight  feeling  of  tenderness  to  a 
constant  and  severe  gnawing  pain,  both  conditions  being  occa- 
sionally interrupted  by  more  or  less  severe  attacks  of  acute 
inflammation,  generally  accompanied  by  an  increase  of  sup- 
puration and  sometimes  by  severe  constitutional  disturbance. 
In  this  condition,  the  presence  of  the  disease  does  not  interfere 
with  a  certain  amount  of  use  of  the  limb ;  and  thus  patients  are 
sometimes  willing  to  endure  for  an  indefinite  period  the  pain  and 
inconvenience  which  attend  it.  We  have  in  such  cases  an  op- 
portunity to  learn  the  natural  history  of  the  disease,  and  may  ap- 
preciate the  amount  of  its  tendency  toward  a  cure — a  tendency 
which,  existing  fifteen  years  in  one  of  my  patients,  and  about 
sixteen  years  in  another,  had  not  sufficed,  at  the  time  of  opera- 


CHRONIC  SINUOUS  ABSCESS  OF  BONE.  35 

tion,to  leave  any  evidences  of  reparation,  much  less  of  cure. 
Among  diseases  which  do  not  tend  to  progressive  disorganiza- 
tion, this  is  a  rare  degree  of  obstinacy,  and  the  reason  of  this 
intractability  and  indisposition  toward  a  cure  I  take  to  exist, 
not  so  much  in  the  nature  of  the  diseased  actions  as  in  their 
unfavorable  physical  conditions.  Thus,  though  the  character 
of  inflammation  in  the  bone  may  be  perfectly  simple  and 
healthy,  yet  the  resulting  abscess  has  assumed  the  form  of  a 
deep  cavity,  communicating  indirectly  and  imperfectly  with 
the  surface  by  means  of  narrow,  ill-placed,  and  often  tortuous 
canals.  Such  a  condition  of  abscess  in  the  soft  parts  is  recog- 
nized as  extremely  unfavorable  for  the  healing  process ;  how 
much  more  so  when,  as  in  bone,  we  have  not  only  an  unfavor- 
able shape,  but  an  unyielding  wall,  which  deprives  us  entirely 
of  the  immense  advantage  which,  in  the  treatment  of  similar 
abscesses  in  the  soft  parts,  we  derive  from  pressure  in  approxi- 
mating the  walls  of  the  suppurating  cavities  ! 

This  view  of  the  local  cause  of  the  obstinacy  of  these  cases  of 
chronic  abscess  of  bone  is  still  further  strengthened  by  several 
considerations.  In  the  first  place,  there  seems  to  be  no  necessary 
or  usual  connection  of  the  inflammatory  action  with  any  constitu- 
tional vice,  as  scrofula,  syphilis,  or  any  other  contamination  of 
the  general  system.  On  the  contrary,  the  affection  seems  to 
occur  by  preference  in  young,  vigorous,  and  robust  persons,  and 
generally  as  the  immediate  consequence  of  injury,  or  of  ex- 
posure to  cold  and  wet,  or  some  other  well-recognized  cause  of 
local  disease.  In  the  second  placa,  the  effect  of  remedies  ad- 
ministered with  a  view  to  their  constitutional  or  alterative 
effect  seems  usually  to  be  inappreciable  in  producing  any  cura- 
tive change  in  the  diseased  part ;  and,  when  any  such  favorable 
effect  is  seen  in  diminishing  pain  or  improving  discharge,  it  ia 
merely  temporary,  and  the  power  of  the  remedy  for  good  is 
soon  exhausted.  This  was  abundantly  illustrated  in  three  of 
my  patients,  in  whom  the  disease  had  longest  existed,  from 
whose  previous  histories,  as  well  as  from  my  own  persevering 
efforts  in  the  use  of  remedies,  I  arrived  at  the  conclusion  that 
the  cure  was  not  to  be  accomplished,  nor  any  important  im- 
provement secured,  by  any  form  of  internal  medication.  Last- 
ly, and  in  contrast  with  the  inefficiency  of  medicine,  the  effect 


36  DISEASES  OF  BONE. 

of  the  operation,  by  which  the  physical  conditions  alone  can  be 
affected,  seems  to  me  the  strongest  proof  that  it  is  upon  these 
physical  conditions  that  the  difficulty  depends,  a  conviction 
which  I  think  must  force  itself  upon  the  mind  of  any  one  who 
has  watched  the  beautiful  reparative  appearances  which  the 
wound  presents  from  the  moment  of  the  operation,  and  the  cer- 
tainty and  soundness  of  the  cure  which  follows  its  thorough 
performance. 

The  following  cases  will  serve  to  illustrate  the  main  features 
of  what  I  think  may  properly  be  termed  chronic  sinuous  ab- 
scess of  bone : 

CASE  I. — George  Brown,  aged  nineteen,  a  German  seaman, 
came  to  the  New  York  Hospital,  November  1Y,  1857,  with  a  dis- 
eased condition  of  his  left  tibia.  It  commenced  about  fourteen 
months  previously,  after  severe  exposure  in  going  round  Cape 
Horn,  and  seemed  at  first  of  a  rheumatic  character,  attacking 
first  one  ankle  and  then  the 'other.  He  was  recovering  from 
the  lameness  caused  by  this  attack,  when,  without  evident 
cause,  the  inflammation  concentrated  itself  upon  the  lower  part 
of  the  left  leg.  He  was  again  confined  to  his  bed,  and  suffered 
much  from  pain  and  fever.  An  abscess  formed  in  about  three 
weeks,  and  broke  on  the  anterior  surface,  about  four  inches 
above  the  joint.  The  swelling  and  inflammation  continued, 
and,  during  about  five  months,  he  was  scarcely  ever  able 
to  leave  his  bed,  except  on  crutches.  During  this  time,  ab- 
scesses formed  and  broke  at  several  points  of  the  swollen  limb, 
and,  at  different  times,  ten  or  twelve  minute  pieces  of  bone 
came  away,  the  largest  not  bigger  than  a  pea.  For  the  last 
few  months,  since  the  acuter  symptoms  have  subsided,  he  has 
been  able  to  go  about  most  of  the  time,  but  not  without  great 
discomfort  and  inconvenience.  On  examination,  the  lower 
third  of  the  tibia  was  found  enlarged  to  more  than  double  its 
natural  size.  Over  it  the  tissues  were  thickened  and  brawny, 
and  the  skin  presented  the  orifices  of  several  sinuses  which  led 
down  into  the  substance  of  the  bone,  and  discharged  a  moder- 
ate quantity  of  pus.  The  probe,  passed  into  any  of  these,  goes 
deeply  into  the  bone,  and  encounters  some  rough,  exposed, 
bony  points,  but  no  distinct  or  considerable  surface  of  seques- 
trum can  be  recognized.  One  of  the  openings  on  the  anterior 


CHRONIC  SINUOUS  ABSCESS   OF  BONE.  37 

surface  communicates  with  another  near  the  malleolus  internus, 
as  can  be  shown  by  passing  in  two  probes,  one  at  either  orifice, 
and  making  them  touch  in  the  middle.  The  ankle-joint  is, 
and  long  has  been,  a  little  swollen,  and  somewhat  stiff  in  its 
movements.  His  general  condition  is  that  of  a  healthy  and 
vigorous  young  man.  "No  suspicion  of  any  syphilitic  taint. 

In  the  light  of  our  previous  experience,  the  diagnosis  here 
was  clearly  made  out,  of  sinuous  abscess  of  bone,  and  the  op- 
eration for  its  cure  was  performed  by  Dr.  Van  Buren,  on  the 
19th,  as,  from  the  proximity  of  the  disease  to  the  ankle-joint,  it 
was  feared  that  inflammation  might  at  any  moment  extend  to 
its  cavity.  By  the  trephine  and  chisel,  the  whole  anterior  wall 
of  the  cavity  in  the  bone  was  removed,  and  every  sinus  freely 
exposed.  They  were  all  found  to  communicate  with  a  central 
cavity,  as  large  as  a  hickory-nut,  which  lay  so  near  the  ankle- ' 
joint,  that  there  appeared  to  be  merely  a  thin  shell  of  bone  be- 
tween it  and  the  cavity  of  the  joint.  The  sinuses,  which  opened 
on  the  anterior  surface  of  the  bone,  were  entirely  exposed  by 
removing  their  bony  covering.  Two  sinuses,  however,  pene- 
trated the  bone  so  deeply,  and  had  their  external  orifices  so 
far  back,  that  it  was  not  thought  best  to  cut  away  all  their 
anterior  wall,  for  fear  of  too  seriously  weakening  the  bone. 
The  portions  of  their  track  which  were  nearest  the  central 
cavity  were  therefore  freely  exposed,  while  their  openings 
through  the  compact  shell  of  the  tibia  were  left  untouched. 
The  whole  of  these  cavities  were  lined  by  a  smooth,  soft,  red- 
dish, and  very  vascular  membrane,  which,  to  the  finger,  felt 
very  thick,  and  seemed  to  be  composed  of  abundant  firm  gran- 
ulations. Through  this  membrane  the  bone-tissue  could  be 
felt,  but  it  was  not  anywhere  extensively  exposed,  or  apparently 
diseased.  The  bone  cut  through  in  the  operation  was  of  mod- 
erate firmness,  and  appeared  to  be  simply  hypertrophied.  It 
bled  freely  when  cut.  The  wound  was  dressed  with  a  view 
to  its  granulating  and  filling  up  from  the  bottom.  Although 
a  slight  attack  of  erysipelas  occurred  on  the  third  day  after  the 
operation,  every  thing  went  on  as  favorably  as  could  be  desired. 
Healthy  suppuration  came  on,  with  good,  firm,  florid  granula- 
tions, and  the  wound  filled  up  rapidly.  On  the  15th  of  Decem- 
ber, it  was  noticed  that  the  sinuses  whose  orifices  had  been  left 


88  DISEASES  OF  BONE. 

on  the  inside  of  the  limb  had  healed  entirely.  He  is  entirely 
free  from  pain.  No  interruption  occurred  in  the  progress  of 
his  cure,  which  was  complete  when  he  was  discharged  from 
the  hospital. 

CASE  II. — Edward  Smith,  aged  nineteen,  I  saw  at  Bellevue 
Hospital,  hy  the  kindness  of  Dr.  C.  D.  Smith,  under  whose  charge 
the  patient  was  admitted.  He  had  presented  himself  at  the 
hospital,  November  11,  1857,  with  an  enlargement  of  the  lower 
part  of  the  left  tibia,  which,  he  said,  had  commenced  with  an 
acute  attack  of  inflammation  of  the  leg,  last  July.  This  attack 
he  attributed  to  a  very  prolonged  exposure  in  fishing  for  oys- 
ters while  the  water  was  yet  quite  cold.  He  went  to  bed 
ill  that  night,  and  the  next  morning  great  pain  in  the  lower 
portion  of  the  leg  announced  the  commencement  of  a  severe 
inflammation,  which  soon  terminated  in  suppuration.  It  was 
opened  in  about  two  weeks,  and  a  large  quantity  of  offensive 
matter  discharged.  Several  other  abscesses  formed  at  intervals, 
and  from  them  small  fragments  of  dead  bone  were  discharged, 
the  largest  not  bigger  than  the  finger-nail.  He  continued  to 
suffer  a  great  deal  of  pain  and  discomfort  about  the  limb,  and 
the  irritation  was  so  great,  and  so  easily  aggravated  by  han- 
dling or  by  exercise,  that  he  was  confined  to  his  bed  during  most 
of  the  time.  When  admitted,  his  general  condition,  though 
obviously  affected  by  long-continued  suffering,  was  tolerably 
good.  The  lower  third  of  the  tibia  was  much  enlarged,  and 
the  integuments  over  it  thickened  and  inflamed.  Five  orifices 
were  situated  on  the  anterior  surface,  into  each  of  which  a 
probe  could  be  passed  deeply  into  the  substance  of  the  bone. 
Here  and  there  the  probe  seemed  to  grate  against  bare  bone, 
but  no  distinct  sequestrum  could  be  discovered.  The  lowest 
orifice  was  about  two  fingers'  breadth  above  the  ankle-joint, 
which  was  not  in  any  way  involved  in  the  disease.  The  dis- 
charge was  not  large,  but  was  somewhat  offensive.  The  case 
was  pronounced  to  be  one  of  sinuous  abscess,  without  necrosis, 
and  the  operation  was  performed  by  Dr.  Smith  on  the  28th  of 
November.  By  the  trephine  and  chisel,  the  sinuses  were  care- 
fully followed  through  the  bone,  and  their  anterior  wall  re- 
moved, thus  laying  them  freely  open  to  the  bottom.  They 
were  all  found  to  communicate  with  one  another,  and  at  the 


CHRONIC  SINUOUS   ABSCESS   OF   BONE.  39 

deepest  part  of  their  course,  toward  the  lower  part  of  the  bone, 
the  cavity  expanded  so  as  to  admit  the  end  of  the  finger,  but 
at  no  point  was  there  any  distinct  or  considerable  chamber; 
which,  in  most  cases  of  this  disease,  indicates  the  seat  of  the 
original  abscess.  Ko  sequestrum  was  found  in  any  part  of  the 
cavities,  but  their  walls  were,  in  places,  rough  or  granular  to 
the  feel,  giving  the  impression  of  an  ulcerated  or  carious  con- 
dition of  the  surrounding  bone-tissue.  The  external  aspect  of 
the  enlarged  part  of  the  bone  was  rough,  and  the  periosteum 
over  it  much  thickened.  The  pieces  of  bone  cut  away  by  the 
trephine  and  chisel  showed  the  natural  spongy  substance  of 
the  bone  hypertrophied,  but  not  otherwise  altered. 

The  wound  was  dressed  lightly  with  lint.  Some  trifling 
feverish  reaction  followed  the  operation,  but  healthy  granula- 
tion was  soon  established,  and,  on  the  10th  of  December,  he 
was  reported  as  improving  rapidly.  Dr.  Smith  since  informed 
me  that  the  further  progress  of  the  case  was  satisfactory,  and 
that  the  wound  healed  entirely,  and  apparently  soundly, 
within  a  few  weeks  after  the  operation. 

These  two  cases  are  presented,  as  among  those  best  illus- 
trating the  usual  characters  of  chronic  sinuous  abscess  of  bone. 
As  deduced  from  these,  and  a  number  of  other  cases,  it  appears 
plain  to  me  that  the  pathological  anatomy  of  the  disease  is  an 
inflammation  of  the  cancellous  tissue  of  the  ends  of  the  long 
bones,  rapidly  terminating  in  suppuration.  The  matter  thus 
rapidly  formed  early  approaches  the  surface  of  the  bone,  and 
soon  reaches  its  compact  outer  shell,  which  it  perforates,  and 
then,  without  obstruction,  attains  the  surface  of  the  integu- 
ment, and  is  discharged.  The  deep  cavity  in  the  bone,  thus 
communicating  with  the  surface  by  a  narrow  and  indirect 
channel,  is  not  properly  evacuated,  and  the  lodgment  of  pus 
in  its  most  depending  portions  provokes  anew  inflammation 
and  suppuration,  which  extends  the  original  excavation,  and 
often  finds  its  way  to  the  surface  by  some  new  channel ;  and 
thus,  by  a  repetition  of  the  original  morbid  process,  the  disor- 
ganization of  the  bone  assumes  the  extent  and  severity  with 
which  it  ultimately  comes  under  our  notice.  These  repeated 
inflammations  cannot  occur  without  exciting  vascular  action  in 
the  surrounding  parts,  and  we  have,  accordingly,  inflammatory 


40  DISEASES  OF  BONE. 

hypertrophy  induced  in  the  affected  portion  of  the  bone,  and, 
later  in  the  disease,  induration  and  eburnatiou,  particularly 
about  the  abscesses  and  their  connecting  sinuses.  With  this 
action  in  the  bone,  we  have  a  corresponding  chronic  inflamma- 
tion and  thickening  of  the  periosteum,  with  osseous  deposits  from 
its  inner  surface  ;  so  that  the  surfaces  of  the  hypertrophied  por- 
tions of  bone,  when  stripped  of  their  periosteum,  have  a  rough, 
irregular,  granulated  appearance,  in  all  respects  similar  to  the 
surface  of  the  involucrum  in  cases  of  necrosis. 

The  discharge,  during  the  earlier  periods  of  the  complaint, 
varies  in  quantity  and  quality  with  the  varying  activity  of  the 
inflammation  ;  but,  in  the  later  stages,  when  the  tendency  to 
abscess-formation  is  exhausted,  and  the  parts  have  become  con- 
solidated by  chronic  inflammation,  the  discharge  is  moderate 
in  quantity,  and,  in  quality,  generally  thin,  sometimes  sanious, 
and  very  rarely  offensive.  Caries  of  the  walls  of  the  cavities 
may  occur  if  the  constitution  be  predisposed  to  scrofula,  or 
contaminated  by  syphilis ;  and,  in  the  same  way,  necrosis  of 
small  portions  of  the  original,  or  of  the  morbidly-indurated 
cancellous  tissue,  may  take  place,  as  an  accidental  complication 
of  the  case ;  but  neither  caries  nor  necrosis  has  any  thing  to  do 
with  the  original  character  of  the  affection,  nor  do  they  usually 
play  any  important  part  in  its  later  history  and  progress. 

A  most  important  feature  in  the  anatomy  of  these  cases  is 
the  disposition  shown  by  the  abscesses  to  approach,  and  to 
involve  the  joint  near  which  they  are  situated.  This  tendency, 
in  the  mere  chronic  form  of  the  disease,  when  the  abscess  has 
not  been  able  to  make  its  way  to  the  surface,  but  remains  a 
source  of  irritation,  pent  up  within  the  swollen  end  of  the  bone, 
is  recognized  by  Mr.  Brodie,  and,  indeed,  by  many  other  ob- 
servers, as  one  of  the  most  dangerous  features  of  the  disease. 
The  same  tendency  is  observable  even  in  the  open  abscess  we 
are  describing.  Though  there  be  no  pent-up  fluid  seeking  an 
outlet  through  the  joint,  yet  the  tendency  seems  very  strong 
for  the  excavations  to  extend  toward  the  nearest  synovial  sur- 
face ;  and,  even  when  no  communication  takes  place,  the  in- 
flammation of  all  the  tissues  round  the  abscess  easily  spreads 
to  the  joint,  and,  rather  by  its  constant  recurrence  than  by  its 
immediate  severity,  seriously  compromises  its  integrity. 


CHRONIC  SINUOUS  ABSCESS  OF  BONE.  41 

The  symptoms  of  this  affection  have  already  been  so  fully 
described  as  not  now  to  require  recapitulation,  but  its  resem- 
blance to  and  its  diagnosis  from  necrosis  demand  a  moment's 
notice.  The  resemblance  is  striking  and  obvious.  The  age 
of  the  patient ;  the  most  common  causes  of  attack  ;  the  early 
symptoms  of  inflammation  of  the  bone,  terminating  in  suppu- 
ration ;  the  numerous  and  successive  openings  ;  the  enlarge- 
ment and  induration  of  the  affected  region ;  the  unchanging 
and  intractable  character,  and  the  interminable  duration  of  the 
disease — are  all  marks  of  identity,  which,  I  believe,  habitually 
deceive  careless  observers,  and  which  require,  for  a  proper  dis- 
crimination, much  care  and  a  thorough  knowledge  of  the  two 
diseases,  and  their  distinctive  characteristics.  There  are,  how- 
ever, some  features  which  are  diagnostic. 

And,  first,  we  have  the  situation  of  the  affection.  In  ne- 
crosis, the  compact,  and,  in  abscess,  the  cancellous  structure, 
are  respectively  the  parts  implicated.  We  have,  therefore,  ne- 
crosis ordinarily  affecting  the  middle  portion  of  the  long  bones, 
which  is  mainly  compact  tissue,  while  abscess  is  formed  at  the 
enlarged  extremities,  where  the  more  vascular,  and  therefore 
more  highly-organized,  spongy  tissue  prevails.  How  uniformly 
this  law  is  obeyed  I  cannot  say.  but  in  eight  cases  which  I  have 
seen  there  has  been  no  exception  to  it. 

Secondly,  the  actions  set  up  in  necrosis,  particularly  if  a 
large  portion  of  the  calibre  of  the  bone  has  perished,  are  for  the 
formation  of  new  bone  around  the  dead  sequestrum,  and,  con- 
sequently, the  enlargement  is  commonly  very  great,  from  the 
thickness  of  the  involucrum,  which,  it  must  be  remembered, 
more  than  supplies  the  place,  as  far  as  mere  bulk  is  concerned, 
of  the  bone  destroyed.  On  the  other  hand,  the  actions  which 
go  on  in  connection  with  abscess  are  merely  those  of  thicken- 
ing of  the  surrounding  bone,  by  a  process  of  inflammatory  hy- 
pertrophy, strictly  analogous  to  the  induration  of  the  tissues 
round  any  series  of  chronic  abscesses  in  the  soft  parts.  The  en- 
largement, therefore,  which  accompanies  necrosis  is  very  great, 
while  that  which  exists  with  abscess  is  comparatively  moderate. 

Thirdly,  the  early  history  of  these  cases  of  abscess  of  bone 
shows  that,  with  each  opening  formed,  there  is  usually  cast  off 
a  small  piece  of  bone,  a  few  days  or  weeks  after  the  opening 


42  DISEASES  OF  BONE. 

has  taken,  place.  This  does  not  occur  with  the  abscesses  of  ne- 
crosis ;  and  it  appears  to  me  that  the  explanation  of  the  differ- 
ence between  the  two  affections,  in  this  respect,  is  not  difficult. 
Where  suppuration  occurs  within  the  substance  of  a  bone,  it 
may  well  be  supposed  that  the  rapid  course  of  the  matter 
toward  the  surface,  bursting,  as  it  were,  through  the  outer 
shell,  before  the  slow  action  of  the  osseous  vessels  can  provide 
by  absorption  for  its  quiet  transit,  will  or  may,  in  many  cases, 
produce  the  death  of  a  small  portion  of  the  compact  tissue 
which  offered  the  first  resistance  to  its  progress  ;  which  small 
fragment  thus  killed  will  separate  and  make  its  appearance,  in 
a  longer  or  shorter  time,  after  the  opening  of  the  abscess.  In 
necrosis,  on  the  other  hand,  all  the  compact  tissue  implicated 
dies  in  mass,  suppuration  occurs  outside  of  the  dead  bone  and 
between  it  and  the  periosteum,  and  no  separation  of  fragments 
usually  takes  place  until  the  whole  mass  begins  to  loosen  from 
its  attachments.  The  pieces  which  come  away  in  abscess  of 
bone  are  described  as  being  very  small,  and  are  often  likened 
to  a  finger-nail ;  and  I  have  so  constantly  met  with  them,  in 
the  history  given  me,  by  the  patients,  of  their  earlier  symptoms, 
that  I  cannot  help  considering  them  as  very  characteristic. 

Fourthly,  I  think  that  there  are,  generally,  less  pain,  less  in- 
convenience, less  inability,  and  less  discharge  produced  by  the 
abscess,  in  its  chronic  condition,  than  by  necrosis,  while  the 
sequestrum  is  present.  So  much  so  is  this  the  case,  that  it 
must  be  extremely  rare  for  a  patient  with  a  large  sequestrum 
in  his  tibia,  for  example,  to  be  able  to  be  about  his  ordinary 
occupations  with  the  same  degree  of  comfort  as  is  often  en- 
joyed by  those  affected  with  the  chronic  abscess. 

Lastly,  the  most  important  of  all  the  diagnostic  signs  is  de- 
rived from  the  information  given  by  the  probe.  In  necrosis, 
there  is  usually  no  difficulty,  if  the  openings  be  free,  in  finding 
the  bare  and  rough  surface  of  the  sequestrum.  In  the  abscess, 
on  the  contrary,  with  openings  equally  free,  no  bare  bone  is 
discovered,  or,  if  any  appears  to  be  touched,  it  is  so  slight  and 
so  uncertain  in  its  indications  as  to  leave  us  in  doubt  whether 
the  sensations  may  not  be  produced  by  the  rude  use  of  the 
probe,  rubbing  off  the  granulations  from  the  surface  of  other- 
wise healthy  bone. 


CHRONIC  SINUOUS  ABSCESS  OF  BONE.  43 

From  the  view  which  has  been  presented,  of  the  anatomical 
features  of  this  affection,  the  character  of  the  operation  neces- 
sary for  its  cure  is  directly  deducible.  If  the  difficulty  lie 
essentially  in  the  physical  conditions  of  the  parts,  then  these 
physical  conditions  must  be  altered.  If  the  abscess  lie  deep 
from  the  surface,  it  must  be  freely  exposed  to  that  surface,  and 
made,  as  nearly  as  may  be,  a  part  of  it.  If  the  channels  through 
which  it  is  discharged  be  narrow  and  indirect,  they  should  be 
made  large  and  direct.  In  short,  if  the  obstinacy  of  the  affec- 
tion depend  upon  its  character  as  a  sinuous  abscess,  then  that 
character  must  be  destroyed,  as  completely  as  possible,  by  con- 
verting it  into  an  open  wound.  In  carrying  out  this  indica- 
tion, it  must  be  remembered  that  it  is  a  cardinal  one,  and  that 
upon  the  thoroughness  with  which  it  is  done  will  depend  the 
rapidity  and  completeness  of  the  cure.  I  am  entirely  convinced 
that  the  failure  in  one  of  my  earliest  cases  was  due  to  the  fact 
that,  not  fully  appreciating  the  importance  of  thoroughness  in 
the  operation,  I  contented  myself  with  opening  the  cavity  of 
the  abscess  by  removing  a  portion  of  its  anterior  wall,  but  did 
not,  as  I  now  think  it  necessary  to  do,  remove  the  entire  cov- 
ering of  the  suppurating  cavity,  both  upward  and  downward, 
and  convert  it  into  a  mere  groove  or  excavation  on  the  surface 
of  the  bone.  Another  case,  of  abscess  of  the  femur,  which  oc- 
curred to  me  soon  after,  presents  an  illustration  of  the  same 
principle,  and  leads  me  somewhat  to  doubt  the  general  applica- 
bility of  the  operation  to  abscesses  in  the  femur.  The  diseased 
bone  is  so  much  more  inaccessible,  covered  as  it  is  with  the 
thick,  muscular  mass  of  the  thigh,  and  the  operation  necessary 
for  fully  exposing  it  is  so  serious  and  extensive,  that  I  fear,  in 
most  cases,  it  would  be  left  incomplete,  and  therefore  ineffect- 
ual. Besides,  even  if  the  operation  be  well  and  thoroughly 
done,  the  suppurating  cavity  in  the  bone  is  so  covered  in  by 
thick,  soft  parts  that,  by  their  healing,  it  in  a  very  short  time 
approaches  again  to  the  character  of  a  cavity  with  narrow  out- 
lets, and  tends  to  reassume  the  appearance  and  behavior  of  a 
einuous  abscess.  When,  however,  the  operation  can  be  thor- 
oughly done,  as  in  the  tibia,  and  in  most  of  the  other  long 
bones,  and  when,  in  addition,  all  the  fistulous  tracks  can  be 
also  freely  laid  open,  the  cure  will  be  speedy  and  complete. 


44  DISEASES  OF  BONE. 

It  is  usually  best  to  commence  the  operation  with  the  tre- 
phine, and  particularly  in  old  cases  where  the  osseous  tissue  is 
apt  to  be  much  consolidated  from  long-continued  and  frequent 
inflammation.  After  exposing  the  main  cavity  by  the  tre- 
phine, then  with  the  gouge  the  whole  of  its  anterior  wall,  and 
such  other  parts  as  may  seem  necessary  in  following  up  the 
fistulous  tracks,  may  be  chiselled  away.  It  is  very  desirable  to 
have  the  tourniquet  applied  to  the  limb  above,  not  so  much 
for  the  saving  of  blood,  of  which  there  is  usually  but  little  lost, 
but  with  the  view  of  keeping  the  cut-bone  surfaces  clean  and 
dry,  so  that  we  may  be  able  to  judge  correctly  of  the  course  and 
condition  of  the  various  tracks  which  it  may  be  necessary  to 
follow.  As  far  as  practicable,  there  is  no  doubt  that  it  is  best 
to  follow  up  and  lay  open  each  of  the  sinuses  which  lead  from 
the  central  cavity  to  the  surface.  That  this  is  not  absolutely 
necessary,  however,  is  shown  by  the  satisfactory  result  reported 
in  Case  I.,  where  two  sinuses,  which  penetrated  the  bone  quite 
far  back,  were  from  motives  of  prudence  left  untouched,  and 
nevertheless  healed  rapidly  and  soundly  as  the  rest  of  the 
wound  began  to  till  up.  If  the  principal  part  of  the  operation 
be  thoroughly  done,  this  will,  I  think,  be  usually  the  case  with 
any  sinuses  which  may  be  allowed  to  remain.  In  any  case 
where  it  seems  necessary,  no  hesitation  need  be  felt  in  making 
deep  and  extensive  chisellings  of  the  bone,  for  the  repair  is 
abundant  and  certain.  We  have  here  to  deal  with  original 
bone-tissue,  thickened  and  hypertrophied  from  long-continued 
inflammatory  action,  it  is  true,  but  with  all  its  original  repara- 
tive  capacity  unexhausted  and  unimpaired.  The  case  is  very 
different  from  the  involucral  covering  of  necrosis,  where  we 
are  dealing  with  an  entirely  new  formation,  one  which  is  itself 
the  product  of  surprising  vital  and  reparative  energy,  which 
energy  may  be  supposed  to  have,  at  least  in  a  great  degree, 
exhausted  itself  in  the  formation  of  the  involucrum,  leaving  no 
excess  to  be  available  in  a  process  of  reformation  after  its 
destruction.  At  the  same  time,  it  is  well  to  avoid  weakening 
the  bone  by  unnecessarily  cutting  away  its  substance,  as  we 
never  can  be  certain  but  that,  by  some  mischance  or  misbehavior 
of  the  wound,  or  of  the  constitution,  the  reparative  actions 
may  be  delayed  or  imperfect. 


DIFFUSE   SUPPURATION.— OSTEOMYELITIS.  45 

The  after-treatment  is  usually  the  simplest  possible.  By 
light  dressings  of  the  wound,  which  is  of  course  left  wide  open, 
it  granulates  from  the  bottom,  and  generally  begins  to  heal  at 
its  edges  before  the  excavation  is  filled  up.  JSTo  tents  or 
sponges  or  deep  dressings  with  lint  will  be  required,  and  time 
only  is  necessary  to  complete  the  cure.  As  soon  as  the  wound 
has  begun  fairly  to  fill  up  and  to  contract,  if  it  be  otherwise  in 
a  healthy  condition,  the  patient  should  be  allowed  to  go  about 
with  a  roller-bandage  to  support  the  limb,  that  he  may  secure 
the  benefit  of  air  and  exercise.  If  an  unhealthy  condition  of 
the  sores  should  persist,  or  if  caries  of  the  bone  should  be  sus- 
pected, constitutional  treatment  will  of  course  not  be  neg- 
lected ;  but,  in  a  large  proportion  of  the  cases  where  the  oper- 
ation has  been  well  done  and  thoroughly  done,  nothing  fur- 
ther will  be  required  to  restore  the  patient  to  perfect  health. 


CHAPTER  Y. 

DIFFUSE   SUPPURATION. — OSTEO-MTELITIS. 

IN  strong  contrast  with  abscess  of  bone,  we  have  that  form 
of  inflammation  in  which  the  suppurative  action  is  not  limited 
by  a  wall  of  fibrine,  but  is  diffused  throughout  the  whole  sub- 
stance of  the  bone.  This  form  of  disease  has  long  been  recog- 
nized by  surgical  writers,  but  particular  attention  has  of  late 
been  drawn  to  it.  by  observations  made  in  the  Crimean  and 
Italian  campaigns,  and  in  our  own  late  war  of  the  Rebellion. 
It  seems  to  be,  in  a  very  eminent  degree,  a  disease  of  crowded 
military  hospitals,  where,  from  the  necessity  of  the  case,  the 
hygienic  conditions  are  often  extremely  unfavorable,  and  it  is 
comparatively  unknown  in  civil  practice.  It  is  a  condition 
induced,  almost  exclusively,  by  injuries  of  the  bones,  and  is  a 
very  serious  and  fatal  complication,  both  of  amputations  and 
of  resections.  From  the  fact  that  its  most  prominent  features 
are  developed  in  the  medullary  cavities,  it  has  received  the 
name  of  osteo-myelitis,  or  inflammation  of  the  marrow  of  the 
bone,  though  it  must  be  understood  that  its  effects  are  by  no 


46  DISEASES  OF  BONE. 

means  confined  to  the  medulla,  but  very  often  involve  all  the 
component  parts  of  the  bone  affected.  The  clinical  history  of 
the  disease  seems  to  be  that,  after  some  injury  or  operation  on 
a  bone,  which  has  involved  its  medullary  cavity,  symptoms  of 
inflammation  of  the  bone  begin  to  show  themselves.  These 
symptoms  are  usually  a  dull,  heavy,  aching  pain  in  the  bone, 
great  tenderness  on  moving  or  handling  the  part,  and  very  soon 
some  swelling  of  the  surrounding  soft  parts.  With  the  super- 
vention of  these  symptoms,  there  is  usually  noticed  a  change  in 
the  appearance  of  the  wound.  The  discharge  diminishes,  and 
for  a  time  dries  up  ;  the  granulations  loss  their  reparative  as- 
pect, and  present  a  dry,  sometimes  a  sloughy  appearance ;  the 
whole  group  of  symptoms  indicating  that  some  serious  disturb- 
ing cause  has  arrested  favorable  progress  of  the  wound  toward 
healing.  With  these,  constitutional  symptoms,  usually  of  a 
very  formidable  character,  are  developed.  Sometimes  a  chill 
may  announce  the  invasion  of  the  disease,  and  very  commonly 
irregular  rigors  are  present  during  its  course.  Fever  soon 
comes  on ;  at  tirst,  of  the  inflammatory  type,  soon  changing  to 
the  typhoid  character.  Delirium  is  often  an  early  sign,  and  in 
all  cases  the  nervous  power  seems  to  be  rapidly  exhausted,  and 
the  patient  soon  presents  those  signs  of  prostration  which  so 
commonly  accompany  the  severer  forms  of  constitutional  irrita- 
tion. Very  often  the  symptoms  merge  into  those  of  pyaemia, 
with  severe  rigors,  followed  by  slight  fever,  and  very  profuse, 
exhaustive  sweats,  rapid  emaciation  and  loss  of  strength,  shriv- 
elling, blueness,  and  maceration  of  the  surface,  low,  muttering 
delirium  and  death,  often  as  early  as  the  third  or  fourth  day. 
If,  while  these  symptoms  are  in  progress,  the  diseased  bone  can 
be  watched,  it  will  be  seen  to  present  an  inflammatory  redness 
of  the  exposed  medulla,  which,  however,  soon  begins  to  be 
specked  with  purulent  dots ;  and  a  thin,  ill-looking  pus,  in  a 
very  short  space  of  time,  begins  to  ooze  from  the  opened  me- 
dullary cavity.  At  the  same  time,  the  periosteal  surface  shows 
that  it  participates  in  the  morbid  action,  and  the  membrane  is 
soon  detached  from  the  bone  by  a  layer  of  exudation  which 
rapidly  becomes  purulent.  Examination  of  the  part  after 
death,  or  after  amputation,  reveals  the  fact  that  these  changes 
reach  far  into  the  medullary  cavity,  in  fact  usually  involving 


DIFFUSE  SUPPURATION.— OSTEO-MYELITI&  47 

the  whole  of  it,  and  often  extending  more  or  less  into  the  can- 
cellous  tissue  both  above  and  below.  Dr.  Lidell,  who  observed 
the  disease  in  our  military  hospitals  during  the  war,  has  found 
three  conditions  of  the  marrow  which  he  regards  as  stages  of 
the  disease,  and  which  he  denominates — 1.  Carnification,  or 
hepatization ;  2.  Suppuration ;  3.  Mortification.  The  first 
stage,  or  that  of  carnification,  Dr.  Lidell  describes  as  charac- 
terized by  a  reddening,  and  increase  of  density  and  tenacity, 
of  the  medullary  substance.  The  color,  he  says,  varies  from 
coppery-red  to  crimson,  to  brown,  and  almost  to  black.  In  this 
stage,  the  normal  proportion  of  fat  in  the  medulla  is  dimin- 
ished, and  the  cellular  elements  of  the  medullary  substance,  viz., 
the  marrow-cells,  are  increased  in  quantity,  and  become  gran- 
ular in  appearance.  Of  course,  the  quantity  of  blood  in  the 
part  is  much  increased,  and  it  is  observed  that  the  inflamed 
medulla  bleeds  easily  when  injured.  The  second  stage,  or  that 
of  suppuration,  supervenes  on  the  former,  and  is  the  character- 
istic condition  of  the  disease.  In  acute  osteo-myelitis  proper, 
the  suppurative  action  is  not  limited  by  the  surrounding  carni- 
fication, but  all  the  tissue  tends  to  break  down  rapidly,  and  in 
fact  simultaneously,  into  the  purulent  state ;  just  as,  in  diffuse 
inflammation  of  the  subcutaneous  cellular  planes,  the  whole 
affected  region  is  in  a  state  of  induration  to-dav,  and  to-morrow 

o  «/  * 

the  whole  indurated  district  has  become  softened  and  infiltrated 
with  pus.  This  suppurative  softening  is  more  or  less  complete 
in  different  cases,  and  goes  sometimes  to  so  great  an  extent 
that  the  semi-fluid  marrow  slowly  oozes  from  the  bone,  a  turbid 
mixture  of  pus,  oil,  and  disintegrated  marrow-cells.  In  that 
more  healthy  form  of  simple  inflammation  of  the  medulla, 
which  we  sometimes  meet  with  in  civil  practice,  it  is  not  un- 
common for  the  suppurative  action  to  be  circumscribed  by  the 
limiting  induration  in  the  form  of  a  perfect  abscess,  but  in  this 
adynamic  form  of  the  disease  we  are  now  considering,  and  to 
which  specially  the  name  of  osteo-myelitis  has  been  given,  we 
find  the  characteristic  behavior  of  the  non-limited,  diffuse,  or 
infiltrated  suppuration.  This  peculiar  tendency  of  the  pus  to 
diffuse  itself  rapidly  over  all  the  affected  region  of  the  bone 
seems  to  be  only  another  evidence  of  that  depressed  vital  power 
which  disarms  and  defeats  healthful  constitutional  reaction,  and 


48  DISEASES  OF  BOXE. 

makes  the  disease  so  dreaded  and  so  fatal.  The  third  stage,  or 
that  of  mortification,  is  only  another  step  in  the  process  of  de- 
struction. The  inflamed  tissue  has  not  vitality  enough  to  dis- 
integrate by  the  slow  process  even  of  diffuse  suppuration,  but 
gives  up  the  contest  and  yields  in  mass  to  complete,  and  often 
very  rapid,  death. 

The  above  outline  of  the  clinical  history  and  pathological 
appearance  in  osteo-myelitis  is  drawn  from  cases  in  which 
gunshot  or  other  injury  of  the  bone  has  been  the  cause  of  the 
disease.  The  following  case  is  an  excellent  example  of  that 
form  of  the  affection  where  the  whole  bone,  including  the 
medulla,  takes  on  acute  suppurative  inflammation  from  causes 
apparently  too  trivial  to  explain  the  occurrence  of  sucli  severe 
consequences.  The  case  was  reported  by  Dr.  Sands  to  the 
Pathological  Society,  and  I  condense  it  from  the  account  pub- 
lished in  the  Medical  Record,  May  15,  1871  : 

"  The  patient  was  an  active,  healthy  boy,  nine  years  old,  who 
was  attacked,  February  12th,  with  severe  pain  in  the  knee. 
Some  tenderness  was  observed  about  the  knee,  though  it  could 
be  moved  without  pain.  This  pain  and  tenderness  continued 
for  a  day  or  two,  but  were  soon  accompanied  with  fever  and 
an  elevation  of  temperature  to  103.  On  the  fourth  day  he 
was  delirious  at  night,  with  a  pulse  of  140,  and  feeble,  the 
tongue  dry,  and  every  thing  indicating  serious  disease.  The 
tenderness  had  now  diffused  itself  along  the  whole  thigh,  deep 
pressure  upon  which  gave  great  pain.  There  was  no  effusion 
into  the  knee-joint,  and  now  no  tenderness  about  it.  There 
was  no  swelling  of  the  thigh,  and  he  was  able  to  move  it  with 
some  freedom.  Careful  measurement  showed  the  left  thigh 
to  be  an  inch  larger  in  circumference  than  the  right.  The 
pain  was  paroxysmal  and  very  severe.  On  the  fifth  day  he 
was  much  worse,  delirium  incessant,  pulse  failing,  temperature 
rising.  The  thigh  was  now  considerably  swollen,  but  not 
cedematous.  He  died  on  the  morning  of  the  sixth  day. 

"  At  the  autopsy,,  the  only  part  of  the  body  examined  was 
the  femur,  but  the  appearances  of  this  bone  sufficiently  ex- 
plained the  nature  of  the  trouble.  The  left  thigh  was  not  meas- 
ured just  before  death,  but  after  death  it  was  found  to  be  two 
inches  more  in  circumference  than  its  fellow.  The  dissection 


DIFFUSE   SUPPURATION.— OSTEOMYELITIS.  49 

was  made  by  an  incision  on  the  outer  aspect  of  the  limb.  The 
muscles  were  somewhat  infiltrated,  but  otherwise  healthy. 
There  were  no  appearances  of  inflammation,  until  the  perios- 
teum was  reached.  The  outer  surface  of  this  membrane, 
throughout  nearly  the  entire  length  of  the  shaft  of  the  femur, 
was  surrounded  with  pus,  accumulated  in  greatest  quantity  at 
a  point  below  and  a  point  above,  on  the  outer  aspect,  and  be- 
hind the  superior  extremity  of  the  bone,  underneath  the  quad- 
riceps femoris.  So  far  as  could  be  ascertained,  there  was  no 
perforation  of  the  periosteum.  This  membrane  was  the  seat  of 
an  acute  cedema,  and  separated  more  readily  from  the  subjacent 
bone  than  it  should.  On  raising  it  from  the  bone,  there  were 
small  deposits  of  pus  here  and  there,  lying  between  the  at- 
tached surface  and  the  bone,  but  these  deposits  were  not  so 
much  in  quantity  as  those  on  the  external  aspect  of  the  mem- 
brane. The  hip  and  knee  joints  were  perfectly  healthy. 

"  On  section  of  the  bone,  it  was  at  once  seen  that  the  focus 
of  the  disease  was  the  interior.  The  whole  of  the  marrow  was 
found  to  be  hyperaemic.  In  some  places  it  appeared  very  soft, 
and  intermingled  with  patches  of  a  whitish-yellow  color,  which 
were  due  to  diffluent  purulent  material.  It  appears  that  this 
infiltration  extended  up  toward  the  epiphysis,  though  it  was 
not  traced  through  the  epiphyseal  line  in  either  direction. 
There  is  no  evidence  to  show  that  the  extension  of  the  disease 
from  within  outward  has  been  one  of  continuity.  There  are 
no  openings  in  the  bone  or  periosteum.  So  far  as  I  have  ex- 
amined, the  inflammation  seemed  to  have  occurred  by  conti- 
guity."' 

Dr.  Edward  Curtis,  who  made  the  microscopical  examina- 
tion of  the  specimen,  gives  the  following  account  of  the  ap- 
pearances presented : 

"  On  section  of  the  bone,  the  marrow,  throughout  its  whole 
extent,  appeared  redder  than  normal ;  that  in  the  medullary 
canal  of  the  shaft  being  of  a  darker  shade  than  the  marrow 
of  the  cancellated  tissue  of  the  extremities.  In  the  medulla 
of  the  shaft,  especially  in  the  upper  half,  were  numerous  foci, 
where  the  substance  was  of  a  pale  cream-yellow  color,  like  pus. 
This  material,  on  microscopic  examination,  was  found  to  be 
mainly  composed  of  closely-aggregated,  small,  roundish  cells, 
4 


50  DISEASES   OF   BONE. 

smaller  than  pus-corpuscles,  pale,  and  very  finely  granular, 
without  visible  nuclei,  embedded  in  an  extremely  viscid  granu- 
lar substance.  Very  little  of  the  usual  fat  of  the  medulla 
was  present  in  this  yellow  material.  The  bright-red  pulp  of 
the  marrow  of  the  shaft  presented  a  much  smaller  proportion 
of  similar  cells  to  those  just  described — a  greater  amount  of 
fat  and  granular  matter — and  was  gorged  with  blood.  In  the 
cancellated  tissue  of  the  extremities,  the  marrow  was  hyper- 
aemic,  but  the  examination  failed  to  detect  any  abnormal  cellu- 
lar elements." 

Dr.  Sands  considered  that,  in  this  case,  the  medulla  was  the 
starting-point  of  the  inflammation ,  though  the  post-mortem 
appearances  indicated  that  the  disease  was  rather  further 
advanced  in  the  periosteum  than  in  the  medulla.  I  do  not 
think  such  a  distinction  can  often  be  made  in  these  acute  bone- 
inflammations  ;  to  my  mind  the  case  affords  a  classical  illustra- 
tion of  the  great  pathological  law  that,  in  such  inflammations, 
the  whole  bone,  both  periosteum  and  medulla,  is  involved  ;  if 
not  in  all  parts  equally  and  simultaneously,  yet  sufficiently  so 
to  show  that  the  mischief  developed  in  each  part  is  the  result 
of  a  process  of  diseased 'action  pervading  the  whole  bone,  and. 
really  belonging  to  it  as  an  entirety,  even  although  it  may  seem 
to  commence  at  one  point  and  spread  to  the  rest.  That  this 
was  the  course  of  the  disease  in  this  particular  case,  would 
seem  to  be  shown  by  the  fact  that,  at  the  end  of  six  days,  all 
parts  of  the  bone  were  so  nearly  equally  implicated.  It  seems 
to  me  extremely  probable  that,  if  this  little  fellow  had  been 
able  to  maintain  himself  under  the  first  onslaught  of  the  in- 
flammation, the  case  would  have  terminated  as  an  ordinary 
example  of  complete  necrosis  of  the  central  parts,  if  not  the 
whole,  of  the  shaft  of  the  femur. 

The  recognized  causes  of  osteo-myelitis  are  usually  con- 
nected with  some  injury  of  the  bone,  as  in  contusion,  fracture, 
amputation,  or  resection,  injuries  which  seem  much  more 
liable  to  be  followed  by  the  disease,  if  air  has  admission  to  the 
wounded  bone.  In  military  practice,  it  is  thought  that  the 
transportation  of  the  wounded  is  a  fertile  cause  of  inflamma- 
tion of  the  bone,  as  we  know  it  to  be  of  the  soft  parts  which 
lie  round  it.  The  jolting  of  compound  fractures,  or  of  resected 


DIFFUSE   SUPPURATION.— OSTEO-MYELITIS.  51 

joints,  over  rough  military  roads,  must  necessarily  induce  a 
rubbing  of  the  wounded  bones  against  one  another,  whereby 
inflammation  would  be  produced,  and  even  in  stumps  the  con- 
tusion of  the  flaps  against  the  bone  may  very  well  be  supposed 
to  set  up  inflammatory  actions,  which  may  involve  the  bone  as 
well  as  the  soft  parts.  Dr.  Lidell  has  particularly  noticed  this 
point,  and  alludes  to  the  corroboration  his  views  have  received 
from  several  surgeons  who  have  directed  their  observations 
toward  this  matter. 

But,  of  all  the  causes  which  may  produce  this  disease,  none 
is  so  eflicient  as  the  impure  air  generated  in  over-crowded  mili- 
tary hospitals.  The  disease  may  be  said  essentially  to  depend 
upon  bad  hygienic  conditions,  and  it  is  because  these  bad  con- 
ditions are  particularly  liable  to  be  found  in  large  hospitals, 
that  it  is  in  these  establishments  we  find  it  almost  exclusively 
present.  Dr.  Lidell  observes :  "  Observation  has  shown  that, 
other  things  being  equal,  the  wards  of  a  hospital  that  are  most 
impure  in  respect  to  their  atmospheric  condition  generally  fur- 
nish the  largest  proportion  of  fatal  cases  of  osteo-myelitis.  Ob- 
servation has  also  shown  that  surgical  patients — for  example, 
those  who  have  sustained  gunshot-fracture,  or  amputation,  and 
are  treated  in  the  portion  of  the  ward  where  the  air  is  most 
likely  to  stagnate,  for  example,  the  corners — are  considerably 
more  likely  to  become  affected  with  destructive  osteo-myelitis 
than  those  who  are  treated  in  other  portions  of  the  same  ward 
where  the  air  is  more  free  from  impurities.  Observation  has 
further  shown  that  surgical  patients  treated  in  hospital-tents, 
if  they  are  properly  pitched  and  policed,  are  much  less  liable 
to  be  seized  with  fatal  osteo-myelitis  than  a  similar  class  of 
patients  treated  in  the  wards  of  a  hospital  building."  These 
views  are  amply  confirmed  by  the  more  limited  experience  of 
civil  practice,  where  the  few  cases  that  do  present  themselves 
can  always  be  traced  to  the  same  vitiation  of  atmosphere, 
which  at  the  same  time  shows  its  ill  influence  by  the  produc- 
tion of  erysipelas,  pygemia,  gangrene,  and  typhoid,  to  all  which 
osteo-myelitis  has  undoubtedly  many  close  relations. 

The  treatment  of  this  dangerous  affection  might  perhaps 
properly  be  said  to  consist  in  its  prevention,  and  it  is  certain 
that,  in  this  direction,  much  may  be  accomplished  by  carefully 


52  DISEASES  OF  BOXE. 

regulating  the  hygienic  conditions  of  the  wounded  man. 
These  hygienic  precautions  are  undoubtedly  the  first  and  most 
important  features  in  the  management  of  osteo-myelitis,  and, 
even  when  the  disease  has  already  declared  itself  in  a  given 
individual,  his  chances  for  life  would  mainly  depend  upon 
what  could  be  done  to  improve  his  hygienic  surroundings. 
Removal  from  the  place  of  original  infection,  separation  from 
others  suifering  from  similar  disease,  change  of  bedding  and  of 
clothing,  scrupulous  cleanliness,  and  abundance  of  pure  air, 
will  often  modify  most  favorably  an  attack  which  threatened 
to  be  fatal ;  and,  in  the  absence  of  this  kind  of  care,  military 
surgeons  are  often  obliged  to  witness  the  utter  inefficiency 
and  even  worthlessness  of  every  other  species  of  management 
whether  medicinal  or  surgical.  Nevertheless,  there  is  some- 
thing left  to  be  done  by  both  general  and  local  treatment. 
The  character  of  the  general  treatment  must  be  mainly  that 
which  supports  the  strength  of  the  patient  through  a  disease  in 
which  that  strength  is  sorely  taxed.  The  best  food  which  the 
stomach  will  receive,  offered  in  such  form  as  to  be  most  easily 
digested  and  assimilated,  with  such  stimulants  as  will  not  ex- 
aggerate the  acuter  symptoms  of  inflammation,  together  with 
the  exhibition  of  such  tonic  medicines  as  will  help  to  sustain 
the  nervous  power,  or  prevent,  as  far  as  may  be,  the  rapid  disin- 
tegration of  the  tissues ;  these  seem  to  be  the  main  indications 
of  general  treatment.  With  regard  to  local  treatment  it  must 
always  be  borne  in  mind  that,  in  all  forms  of  bone-inflamma- 
tion, the  imprisonment  of  the  inflammatory  products  within 
the  unyielding  bone  or  the  scarcely  less  tractable  periosteum, 
forms  one  of  the  most  important  elements  of  suffering  and 
of  danger,  and  that  therefore  the  first  consideration  of  the 
surgeon  should  be,  as  far  as  possible,  and  as  early  as  possible, 
to  give  the  freest  issue  to  any  such  inflammatory  secretions  as, 
by  retention,  would  be  likely  to  be  injurious.  For  this  reason, 
wounds  in  the  soft  parts  should  be  freely  and  unhesitatingly 
opened,  in  such  a  way  that  gravity  will  assist  in  keeping  the 
discharges  free,  and,  if  necessary,  free  incisions  should  expose 
the  bone  to  our  view.  The  tense  and  inflamed  periosteum 
may  often  be  incised  longitudinally,  so  as  to  remove  its  press- 
ure on  the  bone  beneath,  and  in  some  instances  it  has  been 


DIFFUSE  SUPPURATION.— OSTEO-MYELITIS.  53 

recommended,  if  there  be  not  free  exit  of  the  contained  fluids, 
to  perforate  the  bone  with  a  trephine,  in  order  to  afford  an 
easy  route  by  which  the  injurious  fluids  may  find  the  surface. 
These  somewhat  summary  proceedings  are  justified  by  two 
considerations :  First,  the  immediate  effect  of  the  retention, 
under  pressure,  of  the  fluids  within  the  bone  is,  to  enlarge  the 
area  of  disease,  and  intensify  its  severity  ;  and,  secondly,  the 
continuance  of  the  pressure  soon  leads  to  disintegration  and 
death  of  the  bone-tissue  involved ;  and,  if  the  patient  should 
happily  recover  from  his  primary  disease,  he  has  still  to  en- 
counter its  dreadful  secondary  consequences,  in  the  shape  of 
pyaemia,  caries,  and  necrosis.  Again  (and  this  is  the  really 
practical  question  in  the  treatment  of  osteo-myelitis),  what  are 
the  chances  which  the  removal  of  the  diseased  bone  affords  ? 
The  first  efforts  made  in  this  direction  were  made  by  amputa- 
tion or  exsection  of  the  affected  bones,  and  with  a  very  unsat- 
isfactory success.  Vallette,  in  the  Crimean  War,  and  Jules 
Roux,  in  the  Italian  campaigns,  discouraged  by  these  ill  results, 
adopted  the  plan  of  exarticulation,  thereby  removing  the  whole 
of  the  affected  bone,  with  a  success  which  they  report  as  ex- 
tremely marked.  Mr.  Thomas  Longmore,  in  a  paper  read  be- 
fore the  Royal  Medical  and  Chirurgical  Society,  February  8, 
1865,  combats  these  views  of  Drs.  Vallette  and  Roux,  and  in- 
sists that  a  great  many  of  these  cases  may  be  saved  by  allow- 
ing the  disease  to  go  on  to  its  full  development,  and  then,  by 
removing  the  sequestrum,  he  says  the  stump  may  be  saved. 
These  views  of  Mr.  Longrnore  I  consider  unsound  and  founded 
on  an  erroneous  pathology.  The  tubular  sequestra  of  which 
he  speaks,  and  which  he  regards  as  always  the  result  of  osteo- 
myelitis, have  in  fact  no  connection  whatever,  in  most  cases, 
with  this  formidable  disease.  It  is  a  fact  which  I  think  the 
carefully-recorded  experience  of  any  practical  surgeon  will 
verify,  that  the  cases  in  which  these  tubular  sequestra  are 
found  are  the  very  cases  which,  perhaps,  have  done  the  best  in 
their  earliest  stages,  and  that  the  first  symptoms  have  been 
after  the  wounds  have  nearly  closed,  when  gradually-increas- 
ing pain  and  soreness  of  the  stump,  with  an  increasing  instead 
of  a  diminishing  discharge,  have  led  to  the  discovery  of  a 
thickened  bulbous  condition  of  the  end  of  the  bone,  which 


54  DISEASES  OF  BONE. 

after  a  certain  time  has  been  found  to  contain  a  tubular  se- 
questrum. This  is  not  the  history  of  osteo-inyelitis,  and  I 
confidently  believe  that,  in  most  cases,  no  form  or  degree  of 
medullary  inflammation  has  preceded  their  formation.  They 
are  dependent  upon  the  cutting  off,  in  the  amputation,  of  the 
nutritious  artery  of  the  medulla,  whereby  death  of  the  inner 
shell  of  the  bone,  which  receives  its  supply  from  this  artery,  is 
produced,  which  dead  shell  only  announces  its  presence  by  the 
irritation  and  discharge  which  it  excites,  after  it  is  separated 
from  the  living  tissue,  and  has  become  a  foreign  body,  and  by 
the  involucral  thickening  which  it  produces  around  the  seques- 
trum, giving  the  enlarged  bulbous  feeling  to  the  end  of  the 
bone  in  the  stump.  I  have  given,  in  the  chapter  on  Kecrosis, 
a  full  exposition  of  my  views  on  this  matter  (see  page  119),  and 
I  think  a  right  idea  of  the  pathology  of  this  troublesome  form 
of  necrosis  is  in  no  respect  more  necessary  than  as  it  bears 
upon  these  practical  questions  of  osteo-myelitis. 

In  my  judgment,  therefore,  the  conclusions  of  Drs.  Vallette 
and  Roux  are  not  invalidated  by  the  reasonings  of  Mr.  Long- 
more,  and  the  recommendation  of  these  gentlemen,  who  bad 
seen  so  much  of  the  real  disease  in  its  earliest  stages,  to  ampu- 
tate always,  by  removal  of  the  whole  affected  bone,  remains  a 
sound  maxim  in  surgery,  and  one  which  is  fortified  by  a  grati- 
fying success  in  its  performance.* 


CHAPTER  YI. 

RICKETS. 

RICKETS  is  a  disease  so  rarely  seen  in  our  country  that  I 
have  no  experience  which  would  entitle  me  to  speak  of  it  au- 
thoritatively from  my  own  observation.  In  the  Old  World,  and 
particularly  in  the  large  cities,  it  would  seem  to  be  common, 
and  our  best  accounts  of  it  are  pictures  of  the  disease  as  it  exists 
in  Paris  and  London.  Many  writers  have  given  excellent  de- 

*  See,  also,  a  valuable  paper  by  H.  Allen,  M.  D.,  U.  S.  A.,  on  Osteo-myelitis,  in 
American  Journal  of  Medical  Sciences,  January,  1865. 


RICKETS.  55 

scriptions  of  the  affection,  and  its  different  features  have  been 
most  carefully  investigated  by  very  able  observers,  so  that 
there  is  perhaps  no  disease  more  thoroughly  studied  and  better 
understood.  I  know  of  no  better  account  of  what  is  know  non 
the  subject  than  that  which  is  contained  in  the  admirable  lec- 
tures of  Dr.  William  Jenner,  published  in  the  Medical  Times 
and  Gazette,  of  London,  during  the  year  1860.  These  lectures 
are  the  more  valuable,  inasmuch  as  they  are  not  a  mere  resume 
of  other  men's  ideas,  but  are  founded  on  the  author's  large  ex- 
perience in  the  Hospital  for  Sick  Children. 

Rickets,  evidently,  is  not  to  be  regarded  as  in  any  proper 
sense  a  primary  disease  of  the  bones.  It  is  a  peculiar  condition 
of  the  general  system,  showing  itself  by  many  striking  symp- 
toms, of  which  one  very  important  class  present  themselves  in 
the  bones.  So  important,  however,  and  so  characteristic,  and 
so  constant,  are  these  bone-changes,  that  the  affection  very 
naturally  ranges  itself  among  bone-diseases,  and  systematic 
writers  have  agreed  to  give  it  a  place  among  these  disorders. 
The  first  symptoms  of  the  disease  show  themselves  usually  from 
the  third  month  to  the  beginning  of  the  third  year  of  age  ;  not 
commonly  much  later,  and  very  rarely  earlier  than  these  dates. 
Some  writers  speak  of  congenital  rickets,  but  the  best  authori- 
ties deny  its  occurrence.  At  first,  there  are  usually  some  vague 
and  undefined  symptoms  of  deranged  digestion  and  vascular 
action,  which  perhaps,  at  first,  are  not  characteristic,  but  their 
continuance,  or  perhaps  their  recurrence,  soon  shows  that  some- 
thing more  than  mere  temporary  disorder  is  present.  Dr.  Jen- 
ner points  out  three  symptoms  which,  even  in  the  earlier  stages, 
are  characteristic  of  rickets :  The  first  is  an  unnatural  and  pro- 
fuse perspiration  about  the  head  and  neck,  and  upper  part  of 
the  chest.  This  sweating  is  out  of  all  proportion  to  the  heat 
of  the  room,  or  the  exercise  the  child  may  have  taken,  and  also 
out  of  proportion  to  the  same  action  on  all  the  rest  of  the  sur- 
face ;  for  it  constantly  happens  that  the  abundant  perspiration 
will  be  seen  on  the  upper  parts  of  the  body,  while  the  rest  of 
the  skin  is  perfectly  dry.  It  is  mostly  in  sleep  that  these 
drenching  sweats  are  observed,  but  they  may  occur  at  any  time 
from  the  most  trivial  causes.  A  second  symptom  of  approach- 
ing rickets  is  the  desire  of  the  child  to  be  cool  at  night,  leading 


56  DISEASES   OF  BONE. 

it  to  throw  off  the  bedclothes,  and  lie  exposed,  even  during 
cold  weather,  and  when  other  children  are  disposed  to  be  well 
covered.  This  symptom,  it  is  true,  is  so  common  among  chil- 
dren otherwise  perfectly  well,  that  it  cannot  be  considered  as 
by  itself  characteristic,  but  yet  Dr.  Jenner  insists  that  its 
prominence  and  constancy  are  so  decided  as  to  distinguish 
the  rickety  children,  as  a  class,  from  others,  in  a  ward  where 
all  are  sleeping  together.  A  third  symptom,  and  I  suspect  a 
more  characteristic  one  than  either  of  the  preceding,  is  a  gen- 
eral tenderness  to  the  touch  of  the  whole  body.  The  child 
seems  to  shrink  from  even  the  gentlest  pressure,  or  the  most 
careful  handling.  Not  only  this,  but  his  own  movements  seem 
to  give  him  pain.  Dr.  Jenner  says  :  "  The  child  suffering  se- 
verely from  the  general  cachexia  which  precedes  and  accom- 
panies the  progressive  stages  of  the  bone-disease,  ceases  its 
gambols  ;  it  lies  wirli  outstretched  limbs  as  quietly  as  possible, 
for  voluntary  movements  produce  pain.  Its  unwillingness  to 
be  moved  is  so  great  that,  as  Stiebel  has  observed,  it  will  cry 
at  the  approach  of  those  who  have  been  accustomed  to  dance 
it — of  those  at  the  sight  of  whom  it  previously  manifested 
extreme  pleasure.  As  the  disease  progresses,  the  child  gets  a 
peculiar  staid  and  steady  appearance;  its  natural  lively  ex- 
pression is  replaced  by  a  pensive,  aged,  languid  aspect ;  its 
face  grows  broad  and  square,  and,  when  placed  upright  on  its 
mother's  arm,  it  sits,  as  she  says, '  all  of  a  heap.'  Its  spine  bends, 
and  its  muscles  are  too  weak  to  keep  it  erect.  Its  head  seems  to 
sink  between  its  shoulders ;  its  face  is  turned  a  little  upward." 
These  indications  of  constitutional  cachexia  may  be  more 
or  less  distinctly  developed  in  individual  cases,  and  may  occupy 
a  longer  or  shorter  space  of  time.  But  soon  the  peculiar  fea- 
ture of  the  disease  begins  to  show  itself,  namely,  a  change  in 
the  condition  of  the  bones.  Sometimes,  we  are  assured,  that 
this  change  in  the  bones  shows  itself  at  the  same  time  with  the 
constitutional  symptoms  above  described,  and  sometimes  even 
before  their  appearance.  In  some  cases,  too,  there  is  little  or 
no  constitutional  suffering  from  the  beginning  to  the  end  of 
the  disease.  These,  however,  are  the  exceptions  to  a  rule  and 
mode  of  progress  which  are  tolerably  regular  and  constant.  Dr. 
Jenner  classifies  the  most  striking  anatomical  lesions  in  rickets 


RICKETS.  57 

under  seven  heads,  of  which  five  have  reference  to  changes  in 
the  bones,  and  two  to  alterations  in  the  soft  parts.  Thus,  he 
says  we  have :  X 

1.  Enlargement  of  the  ends  of  the  long  bones. 

2.  Softening  of  all  the  bones. 

3.  Thickening  of  the  flat  bones. 

4.  Deformities  which  follow  from  mechanical  causes  acting 

o 

on  the  softened  bones. 

5.  Arrest  of  growth  of  the  bones,  muscles,  etc. 

6.  Certain  lesions  of  the  pericardium,  lungs,  and  spleen, 
the  direct  consequence  of  the  thoracic  deformity. 

7".  Less  constant  but  highly-important  changes  affecting 
the  nutrition  of  the  brain,  spleen,  liver,  lymphatic  glands,  and 
other  organs. 

1.  The  Enlargement  of  the  Ends  of  the  Long  Bones. — This 
seems  to  be  one  of  the  earliest  and  most  distinctive  features  of 
the  disease.     It  is  observed  in  all  the  bones,  but  is  most  striking 
in  the  wrist,  the  ankle,  the  elbow,  the  knee,  and  the  articular  ex- 
tremities of  the  ribs.    The  change  seems  to  be  one  in  which  the 
cartilaginous  substance  of  the  ends  of  the  bone  is  developed  in 
excess,  without,  however,  any  increase  in  the  ossific  action,  so 
that  the  end  of  the  bone  grows  larger  than  it  should  be  at  the 
given  age,  while  ossification  is  retarded,  and  hence  we  have 
the  joint-end  of  the  bone  not  only  enlarged  but  softer  than 
natural  from  the  absence  of  calcareous  deposit  in  the  exaggerated 
cartilaginous  tissue.     The  periosteum  is  also  very  considerably 
thickened  over  this  enlarged  end  of  the  bone,  thus  adding 
very  materially  to  the  deformity  which  is  so  characteristic  of 
the  early  stages  of  rickets. 

2.  The  Softening  of  all  the  Bones. — This  is  the  most  peculiar 
and  most  interesting,  and  in  many  respects  the  most  important 
feature  of  rickets.     It   has   accordingly   been   very   carefully 
studied  by  all  the  writers  on  this  subject.     It  is  pretty  certainly 
ascertained  that  this  softening  of  the  bones  depends  in  most 
cases  upon  a  want  of  a  due  proportion  of  earthy  salts  in  their 
composition.     Thus,  as  a  general  statement,  it  may  be  said 
that,  while  in  healthy  bone  we  have  one  part  of  organic,  and 
two  parts  of  inorganic  matter,  in  rickety  bone  the  proportion 
is  exactly  reversed,  and  we  have,  in  a  given  weight  of  bone,  two 


58  DISEASES  OF  BONE. 

parts  of  organic,  aiid  only  one  part  of  inorganic  constituents. 
Besides  this,  however,  there  is  a  rarefaction  of  the  bone-tissue 
which  may  or  may  not  coexist  with  the  changes  in  its  chemical 
composition.  Of  these  two  conditions  of  the  bone,  Rokitansky 
says :  "  The  texture  of  the  bones  is  affected  in  two  ways,  of 
which  sometimes  one  preponderates,  and  sometimes  the  other. 
In  the  first  case,  the  bone  is  rarefied  and  increased  in  size,  ex- 
panded, in  fact.  A  pale,  yellowish-red  jelly  is  effused  into  its 
enlarged  canals  and  cells,  into  the  medullary  cavity,  and  even 
under  the  periosteum.  The  bone  itself  is  abundantly  supplied 
with  vessels,  and  full  of  blood,  and  its  color  is,  therefore,  darker 
than  natural,  and  red.  Occasionally  this  change  reaches  to 
such  a  degree  that  the  cells  of  spongy  bones,  and  those  in  the 
interior  of  medullary  tubes,  become  excessively  distended,  and, 
as  their  walls  disappear,  are  merged  in  larger  cavities  :  medul- 
lary cavities  at  last  become  single,  spacious  chambers,  and  the 
bones  uncommonly  soft  and  fragile.  In  the  second  case,  in 
addition,  it  is  deprived  more  or  less  of  its  mineral  constituents  ; 
and  sometimes  it  is  completely  reduced  to  its  cartilaginous  ele- 
ment, and  appears  like  a  bone  that  has  been  steeped  in  acid. 
The  bony  corpuscles  are  empty,  and  their  rays  have  disap- 
peared, and,  when  this  is  the  case,  the  lamellar  structure  is  here 
and  there  obliterated ;  at  other  parts  the  lamellae  appear,  as  it 
were,  to  have  fallen  asunder,  and  the  corpuscles  are  seen  quite 
distinctly  interposed  between  them.  It  is  upon  this  condition 
that  the  softness,  the  flexibility,  etc.,  of  rickety  bones  depend. 
These  two  conditions  exist  together,  as  has  been  remarked,  and 
sometimes  one  preponderates,  and  sometimes  the  other ;  it  is, 
however,  remarkable  that,  in  cases  of  general  rickets,  the  reduc- 
tion of  a  bone  to  its  cartilaginous  elements  so  preponderates  in 
some  bones  as  to  go  on  even  to  completion  without  any  trace 
of  rarefaction."  He  gives,  also,  the  following  analysis  of  a 
scapula  and  a  humerus  affected  by  rickets  : 

Scapula — specific  gravity 0.612 

Cartilage,  vessels,  and  fat 81.12  organic  constituents. 

Basal  phosphate  of  lime  and  of 

magnesia 15.60  ) 

Carbonate  of  lime 2.66  L  18.88  inorganic  constituents. 

Salts,  soluble  in  water 0.62   \ 

The  humerus  contained  10.54  per  cent,  of  fat. 


RICKETS.  59 

This  may  be  compared  with  an  analysis  which  he  gives  fur- 
ther on  of  a  simple  induration  of  the  skull  of  a  lunatic : 

Specific  gravity 1.911 

Cartilage  and  vessels ,  83.41  organic  constituents. 

Basal  phosphate  of  lime,  etc. . .  .54.10  ~\ 

Carbonate  of  lime 10.45 

T»I       ,    ,      „              .  -i  AA   r  66.59  inorganic  constituents. 

Phosphate  of  magnesia 1.00   I 

Salts,  soluble  in  water . .  1.04  I 

Or  with  the  following,  taken  from  Carpenter,  of  the  healthy 
bone  of  a  man  twenty-five  years  of  age  : 

Cartilage  and  fat 31.03  organic  constituents. 

Phosphate  of  lime,  etc 59.63  "j 

Carbonate  of  lime 7.33 

Phosphate  of  magnesia 1.32   [  68'9*  ^organic  constituents. 

Salts,  soluble  in  water 69  j 

Besides  these  changes  in  the  chemical  composition  of  bone, 
there  is  another  less  distinctly  noticeable,  but  perhaps  not  less 
important,  which  exists  in  the  animal  matter  of  the  bone, 
whereby  it  is  so  altered  that,  on  boiling,  it  does  not  yield  either 
chondrin  or  gelatin,  as  is  the  case  in  healthy  cartilage  and 
healthy  bone.  What  precise  relation  this  change  may  have 
to  the  softened  condition  of  the  bone-substance  has  not  yet  been 
clearly  ascertained. 

3.  The  thickening  of  the  fiat  T)ones  of  the  cranium  seems  to 
be  another  illustration  of  the  irregular  nutritive  behavior  of  the 
bone-substance  in  rickets.  The  thickening  is  associated  with 
the  other  changes  noted  above,  and  is  sometimes  very  great. 
It  is  usually  just  at  the  growing  margin  of  the  bone,  and  least 
at  the  centres  of  ossification,  obeying  thus  the  same  general 
law  by  which  the  earliest  and  most  marked  changes  in  the  long 
bones  are  found  at  their  extremities,  where  growth  is  most 
active. 

In  contrast  with  this  excess  of  deposit,  we  have,  in  some 
cases,  as  an  early  rachitical  symptom,  a  deficiency  of  bony  mat- 
ter in  certain  points  of  the  cranial  bones,  which  has  been  called 
craniotabes.  This  curious  affection  is  most  frequently  seen  in 
quite  young  children,  and  affects  the  posterior  parts  of  the  cra- 
nium rather  than  the  lateral  or  anterior.  It  consists  of  a  defi- 


60  DISEASES  OF  BONE. 

ciencj,  probably  from  absorption,  of  the  earthy  constituents  of 
the  bone,  in  circumscribed,  irregular,  and  sometimes  numerous 
spots  ;  these  deficient  points  not  being  found  at  the  ossifying 
edges,  but  rather  in  the  central  districts  of  the  bone  where  ossi- 
fication has  been  longest  complete.  The  following  case  is  re- 
ported by  Dr.  A.  Jacobi,  in  the  New  York  Medical  Journal 
for  November,  1865 :  "  A  child  aged  five  months  died  after 
having  suffered  from  frequent  convulsions  during  a  fortnight 
preceding  its  death.  The  convulsion  was  usually  announced 
by  an  attack  of  laryngismus  stridulus,  but  no  other  cerebral 
symptoms  were  manifest.  In  other  respects,  it  had  seemed  to 
be  a  tolerably  healthy  child,  though  it  presented  the  enlarged 
epiphyseal  extremities  of  the  long  bones  so  characteristic  of 
rickets. 

"  On  examination  after  death,  the  dura  mater  was  found 
tightly  adherent  in  the  situation  of  the  lambdoidal  suture.  The 
upper  portion  of  the  occipital  bone  and  the  lower  portion  of 
the  parietal  bones  have  been  removed,  and,  on  holding  them  to 
the  light,  there  are  evidently  a  great  many  places  in  which 
there  is  apparently  no  osseous  tissue  whatever — especially  is 
this  the  case  on  the  right  side.  I  forgot  to  state  that  the  occi- 
put of  the  child  appeared  at  one  portion  to  be  flattened  ;  this 
condition  can  now  be  appreciated  in  the  general  configuration 
of  the  bones.  The  right  parietal  is  evidently  the  one  which  is 
most  affected ;  the  left  parietal  bone  shows  a  number  of  very 
distinct,  softened  spots,  in  which  there  is  no  appearance  of  bony 
tissue.  Through  one  spot,  where  I  had  previously  removed 
the  pericranium,  I  was  enabled  to-day  to  see  a  large  letter. 
There  was  softening  of  the  cerebral  substance,  and  there  was 
further  some  effusion  in  the  arachnoid  sac,  which,  judging  from 
the  symptoms,  must  have  occurred  during  the  last  days  of  life. 
There  was  a  little  effusion  in  the  spinal  canal,  which  would 
flow  down  into  the  cranium  when  the  child  was  turned  over." 
All  the  other  organs  were  healthy.  The  periosteum  was  very 
easily  stripped  off  the  parietal  bones. 

In  the  American  Journal  of  Obstetrics,  published  in  New 
York,  in  the  number  for  November,  1870,  Dr.  Jacobi  has  pub- 
lished a  very  full  and  very  able  paper  on  the  subject  of  cranio- 
tabes,  and  its  relations  to  the  other  better-known  rachitical 


RICKETS.  61 

changes.  He  says  that  the  peculiar  change  we  are  considering 
is  apt  to  commence  at  about  the  age  of  three  or  four  months, 
when  the  rachitical  condition  of  the  cranium  can  usually  be 
appreciated  by  the  finger  gently  pressed  upon  the  softened 
spots.  Dr.  Jacobi  considers  that  "  the  clinical  cause  of  the 
predilection  of  rachitical  absorption  for  the  occipital  portion  of 
the  head  must  be  sought  for  in  the  recumbent  posture  of  the 
infant.  The  whole  cranium  gets  softened,  more  or  less;  the 
side  on  which  the  patient  is  mostly  resting  gets  flattened,  and 
the  corresponding  oblique  diameter  shortened,  but  absorption 
will  take  place  at  a  number  of  spots  which  fulfil  the  following 
conditions : 

"  1.  Rachitical  deposits  must  have  taken  place  very  copi- 
ously. 

"  2.  The  weight  of  the  brain  must  fall  on  the  softened  spot. 

"  3.  The  pressure  of  the  pillow  must  form  a  third  factor. 

"  Thus,  in  every  instance,  one  of  the  sides  is  flattened — 
mostly  the  right — and  the  majority  of  the  softened  spots  are 
found  on  that  flattened  right  side." 

Dr.  Jacobi  considers  the  prognosis  of  craniotabes  as  no  more 
unfavorable  than  that  of  the  other  signs  of  the  rachitical  dis- 
ease, provided  there  be  no  complication  on  the  part  of  the  brain 
or  its  membranes.  The  liability  to  this  complication  gives 
a  somewhat  grave  character  to  the  prognosis. 

4.  The  importance  attached  to  the  softened  condition  of  the 
bones  in  this  disease  is  derived  from  the  fact  that  this  altered 
condition  leads  to  deformities  from  mechanical  causes  acting 
upon  the  skeleton,  and  that  these  deformities  become  perma- 
nently impressed  upon  the  bone  as  the  original  disease  disap- 
pears, thus  leaving  its  life-long  and  ineffaceable  traces  behind  it ; 
traces  which  mark  themselves  as  the  causes  of  some  of  the  most 
serious  diseases  and  dangers  to  which  the  frame  is  liable.  These 
changes  have  been  very  carefully  studied,  and  occur  most  dis- 
tinctly and  most  commonly  in  the  spine,  in  the  thorax,  in  the 
pelvis,  and  in  the  long  bones  of  the  extremities.  The  spine 
presents  an  increase  in  its  natural  curvatures,  and  the  change 
is  therefore  usually  confined  to  the  antero-posterior  directions. 
A  lateral  curve  of  the  spine  is  sometimes  associated  with  other 
more  marked  antero-posterior  curves,  but,  as  a  primary  or  a 


62  DISEASES   OF  BONE. 

principal  change,  lateral  curvature  is  rare.  The  cervical  ver- 
tebra are  so  softened  that  they  can  no  longer  support  the  great 
weight  of  the  head,  which  therefore  falls  either  backward  or 

O 

forward.  Dr.  Jenner  explains  its  falling  most  commonly  back- 
ward by  the  desire  of  the  child  to  see  what  is  going  on  around 
it,  which  it  can  do  more  easily  with  the  head  thrown  back  than 
when  it  is  allowed  to  fall  forward  on  the  sternum.  There  is 
also  a  curve  developed  in  the  dorsal  and  lumbar  region,  which, 
in  the  dorsal  region  particularly,  is  sometimes  extreme,  and 
forms  a  very  important  element  in  the  accom- 
panying deformity  of  the  chest.  The  femur 
becomes  curved  outward  and  forward  (Fig. 
8),  the  tibia  outward,  and  these  curves  be- 
come much  increased  as  the  child  begins  to 
walk.  The  radius  and  ulna  are  also  some- 
what bent,  according  to  the  muscular  actions 
they  have  been  subjected  to,  and  are  not  un- 
frequently  twisted  as  well  as  bent;  The  hu- 
merus  usually  bends  about  the  insertion  of 
the  deltoid,  and  the  clavicle,  from  transmit- 
ting all  the  forces  which  act  upon  the  body, 
through  the  upper  extremity,  is  often  bent 
at  several  points,  and  at  a  very  considerable 

FIG.  8.— (Bellevue  Hospital   angle. 

Collection.)  in«r»ii  • 

Ihe  deformity  of  the  thorax  is  very  marked, 
and  exercises,  no  doubt,  a  great  influence  on  the  health  of  the 
child,  by  the  imperfect  manner  in  which,  both  from  its  shape 
and  its  softness,  it  performs  its  part  in  the  respiratory  acts. 
Dr.  Jenner  believes  that  this  is  a  very  important  element  in 
the  mortality  of  rickety  children,  who  may  be  attacked  with 
any  pulmonary  inflammation  ;  the  disease  demanding  increased 
play  of  a  chest  which  cannot  fully  respond  to  the  demand,  and, 
therefore,  cannot  lend  to  the  little  sufferer  that  aid  which  the 
increased  expansion  of  the  cavity  brings  to  healthy  children 
suffering  in  the  same  way.  In  regard  to  the  change  of  shape, 
Dr.  Jenner  says  :  "  The  back  is  flattened.  The  ribs  are  bent 
at  an  acute  angle,  where  the  dorsal  and  lateral  regions  unite. 
At  that  part,  the  lateral  diameter  of  the  thorax  is  the  greatest. 
From  it  the  ribs  pass  forward  and  inward  to  the  point  where 


RICKETS.  63 

the}7  unite  with  their  cartilages  ;  on  that  line  the  lateral  diame- 
ter of  the  thorax  is  the  least,  the  cartilages  curving  outward 
before  turning  in  to  unite  themselves  to  the  sternum.  The 
sternum  is  thrown  forward,  and  the  antero-posterior  diameter 
of  the  thorax  is  abnormally  great.  The  consequence  of  the 
direction  of  the  ribs  being  inward,  and  of  the  cartilages  out- 
ward, is  that  the  thorax  is  grooved,  from  above  downward,  on 
its  antero-lateral  face,  from  the  first  to  the  ninth  or  tenth  rib  ; 
the  deepest  part  of  the  furrow  being  'just  outside  the  nodes 
formed  where  the  ribs  and  cartilages  meet.  This  groove  ex- 
tends lower  on  the  left  than  on  the  right  side,  but  it  is  deeper 
on  the  fifth  and  sixth  ribs  on  the  right  than  on  the  left  side ; 
the  heart  and  liver  respectively  supporting,  to  some  extent, 
their  corresponding  ribs.  The  points  of  maximum  recession 
correspond  to  the  fifth,  sixth,  and  seventh  ribs.  A  little  below 
the  level  of  the  nipple  the  chest  expands  considerably,  the 
chest-walls  being  borne  outward  by  the  liver,  stomach,  and 
spleen.  If  we  examine  the  thoracic  walls  from  the  inside,  the 
appearance  is  most  remarkable :  where  the  ribs  join  with  the 
cartilages  there  are  much  greater  projections  than  on  the  out- 
side ;  but  the  eleventh  and  twelfths  ribs,  which  are  not  inflexed, 
have  the  same  enlargement  on  the  inside  as  on  the  outside." 
Add  to  these  statements  as  to  shape  the  fact  that  the  bones  are 
yielding  from  their  softness,  and  add  still  further  the  fact  that 
the  muscles  are  weakened  in  their  tone  as  well  as  their  texture, 
and  I  think  it  is  not  difficult  to  understand  how  much  below 
the  normal  standard  of  healthy  children  the  respiratory  power 
of  rickety  children  falls,  and  how  little  it  is  suited  to  meet  the 
increased  respiratory  necessities  of  severe  disease. 

The  pelvis,  in  rickets,  undergoes  changes,  not  less  marked, 
but  perhaps  less  constant,  in  their  eifect  upon  the  shape  of  the 
structure.  These  consequences  are  due  to  the  weight  of  the 
body  being  transmitted  through  the  pelvis,  and  received  upon 
the  heads  of  the  femora,  and  as  this  weight  is  very  varying  in 
its  action,  according  as  the  child  walks,  or  creeps,  or  sits,  or 
lies,  or  as  either  of  these  motions  pr.epon  derates  over  the  others,  so 
it  must  necessarily  be  with  the  resulting  deformity,  it  showing 
the  effects  of  pressure  in  that  direction  in  which  the  pressure 
is  most  frequently  and  most  forcibly  made,  and  varying  there- 


64  DISEASES    OF  BONE. 

fore  M'ith  the  habitual  muscular  actions,  as  well  as  with  the 
habitual  attitudes  and  positions  he  tends  to  assume.  The  in- 
terest attac  he  to  these  changes  in  the  rickety  pelvis  depends 
mainly  upon  the  effect  of  the  resulting  deformity,  in  so  chang- 
ing the  size  and  form  of  the  outlets  that  the  process  of  par- 
turition, in  after-life,  may  become  difficult  or  impossible.  It 
is  mostly  to  these  changes  that  are  due  those  dreadful  cases 
in  which  the  obstetric  practitioner  is  obliged  to  resort  to  his 
most  fearful,  and,  unfortunately,  most  doubtful '  expedients,  to 
terminate  a  process,  which  is  only  impeded  by  the  mechanical 
disproportion  between  the  head  of  the  child  and  the  openings 
it  must  traverse.  These  terrible  deformities  are  produced 
mainly  by  rickets,  but  sometimes  also  by  the  disease  of  the 
bones  known  as  malacosteon,  a  disease  which  has  this  in  com- 
mon with  rickets,  that  in  it  the  texture  of  the  bone  is  softened, 
and  yields  to  pressure.  This  pressure  is  considered  to  act  dif- 
ferently on  the  pelvis  in  these  two  diseases,  so  that  it  is  thought 
that  the  deformity  of  the  pelvis  produced  by  rickets  and  that 
by  malacosteon  differ  so  much  that,  by  mere  inspection  of  the 
bones,  the  diseases  can  generally  be  distinguished  from  one 
another.  In  general  terms,  the  difference  can  be  expressed  by 
stating  that,  in  rickets,  the  pressure  acts  from  before  backward, 
so  that  the  promontory  of  the  sacrum  approaches  the  pubis, 
thereby  narrowing  the  antero-posterior  diameter  of  the  outlet, 
while  the  transverse  diameters  are  increased ;  while  in  mala- 
costeon it  seems  that  the  pressure  of  the  femora,  on  each  side, 
tends  to  thrusting  in  of  the  sides  of  the  pelvis,  so  that  the  lateral 
diameters  are  diminished,  while  the  antero-posterior  are  length- 
ened, giving  the  outlet  what  Dr.  Tyler  Smith  calls  a  rostrated 
form.  Besides  these  two  modes  of  deformity  there  is  a  third, 
more  rare  than  either,  in  which  the  pelvis  is  obliquely  distorted, 
the  pubis  being  thrust  either  to  one  side  or  the  other  of  the 
median  line,  so  that  the  pelvis  has  a  twisted  appearance,  and 
the  lines  of  the  outlet  differ  on  the  two  sides,  according  as  the 
pelvis  is  pushed  to  one  side  or  the  other  of  the  promontory  of 
the  sacrum.  Of  this  oblique  distortion,  Naegele  was  the  first 
to  give  a  description,  in  a  special  memoir  which  he  published 
on  this  subject,  in  which  he  details,  most  accurately  and  care- 
fully, the  features  presented  by  thirty -seven  obliquely-distorted 


RICKETS.  65 

pelves,  which  he  had  the  opportunity  to  study.  Writers  do 
not  seem  to  agree  that  this  peculiar  deformity  is  ever  the  sole 
result  of  rickets,  or  of  malacosteon.  Naegele  believes  that  it 
is  an  original  failure  in  the  process  of  development,  and  he 
gives  many  reasons  for  his  belief.  Of  the  proper  rickety  pel- 
vis, Dr.  Tyler  Smith  says :  "  The  sacrum,  in  such  cases,  is 
placed  more  horizontally  than  natural ;  the  promontory  pro- 
jects forward,  and  sinks,  as  it  were,  into  the  cavity  of  the  pel- 
vis, so  as  to  bring  the  fourth  or  fifth  lumbar  vertebra  into  the 
position  naturally  occupied  by  itself.  The  sacrum  is  somewhat 
diminished  in  depth,  though  not  so  much  so  as  in  the  case  of 
malacosteon  distortion  ;  its  vertical  and  lateral  curvatures  are 
both  diminished,  and  the  bone  is  consequently  very  much  flat- 
tened. The  apex  of  the  sacrum  and  the  coccyx  are  bent  acutely 
forward  and  inward.  The  wings  of  the  iliac  bones  are  some- 
what flattened,  and  everted,  and  carried  bodily  forward  toward 
the  anterior  part  of  the  pelvis.  The  symphysis  pubis  is  some- 
times projected  inward,  so  as  to  give  the  inlet  of  the  pelvis  an 
hour-glass  shape.  The  tuberosities  of  the  ischia  are  separated, 
so  as  to  increase  both  the  transverse  diameter  of  the  outlet  and 
the  width  of  the  sub-pubic  arch." 

5.  It  is  only,  however,  when  we  add  to  these  statements 
the  fact  that  arrest  of  growth  always  accompanies  the  dis- 
tortions of  rickets,  in  a  greater  or  less  degree,  that  we  can 
form  a  proper  idea  of  the  actual  change  produced  by  the 
disease,  and  the  amount  of  impediment  which  the  two  con- 
ditions combined  may  produce  to  the  passage  of  the  fetal 
head  through  the  outlets.  On  this  point,  Dr.  Alexander  Shaw, 
in  his  admirable  essays  on  rickets,  in  the  Medico- Chirurgical 
Transactions,  vol.  xxvi.,  says,  in  a  foot-note :  "  To  ascertain 
the  average  amount  of  this  deficiency,  and  thus  judge  of  the 
share  which  the  consequent  smallness  of  the  pelvis  has  in  im- 
peding the  passage  of  the  child  in  parturition,  and  causing 
difficult  labor,  I  took  the  measurements  of  twenty-nine  de- 
formed pelves,  from  patients  of  the  female  sex,  and  compared 
them  with  those  of  the  natural  female  pelvis.  The  result  was, 
that  the  deformed  pelves  fell  short  of  their  normal  dimensions 
by  nearly  one-quarter  of  their  proper  size.  So  that,  in  women 
distorted  from  rickets,  two  distinct  causes  give  rise  to  difficult 
5 


66  DISEASES  OF  BONE. 

labor :  First,  the  distorted  condition  of  the  pelvis,  consequent 
on  the  softened  state  of  the  bones,  and  the  compression  to 
which  they  have  been  subjected.  Secondly,  the  general  small- 
ness  of  the  bones  depending  on  the  pelvis  having  been  origi- 
nally, at  childhood,  of  remarkably  diminutive  size,  and  on  its 
growth  having  been  interrupted  by  the  attack  of  rickets." 

The  changes  which  rickets  produces  on  the  shape  of  the 
head  have  been  particularly  studied  by  Mr.  Shaw ;  and  the 
results  of  his  numerous  observations  lead  him  to  several  inter- 
esting conclusions :  First,  that  the  size  of  the  whole  head  in 
rickety  persons  is  below  the  .standard  dimensions.  Secondly, 
that  the  degree  of  deficiency  is  greater  in  the  face  than  in  the 
cranium  ;  and  that  therefore,  thirdly,  the  apparent  great  size 
of  the  head  in  these  persons  is  due,  not  to  the  actual  size  of  the 
cranium,  but  to  its  disproportion  to  the  size  of  the  face.  The 
mode  in  which  this  disproportion  is  produced  seems  to  be  by  a 
failure  on  the  part  of  the  rickety  skeleton  to  obey  that  law  of 
development  which  Mr.  Shaw,  in  his  most  ingenious  papers, 
has  shown  to  be  a  universal  one  in  the  healthy  individual.  He 
shows,  very  clearly,  that  the  head  and  upper  part  of  the  body 
are,  in  the  foetus,  developed  much  in  advance  of  the  pelvis  and 
lower  extremities,  and  this,  for  obvious  reasons  connected  with 
the  well-being  of  the  foetus  and  of  the  young  infant,  and  that 
from  the  time  of  birth  this  unequal  development  of  the  upper 
over  the  lower  parts  of  the  body  is  gradually  disappearing  by 
the  increased  rapidity  of  growth  of  the  lower  half.  In  rickets, 
he  is  satisfied  that  this  accelerated  rate  of  development  of  the 
lower  parts  of  the  body  is  checked,  and  upon  this  theory  he 
explains  the  changes  which  rickets  impresses  upon  the  skeleton. 
It  retains  its  infantile  proportions  rather  than  those  of  adult 
age,  and  this  he  proves  to  be  a  fact  by  numerous  and  very 
careful  measurement  statistics.  The  same  law,  which  he  shows 
to  guide  the  development  of  the  whole  body,  governs  also  the 
development  of  head  and  face.  The  cranium  of  the  foetus  bears 
a  much  larger  proportion  to  the  face  than  does  that  of  the 
adult.  In  rickets,  this  disproportion  more  or  less  remains,  and 
the  face  does  not  gain  on  the  cranium  as,  in  the  healthy  indi- 
vidual, it  should  do,  and  therefore,  as  all  the  parts  grow  to- 
gether toward  adult  size,  the  face  is,  like  the  lower  extremities, 


RICKETS.  67 

left  behind  in  the  progress  of  development,  and  the  adult  pre- 
sents some  of  the  features  of  infantile  proportion,  while,  per- 
haps, the  whole  frame  may  have  attained  a  fair  average  size. 
In  speaking  of  this  effect  of  rickets,  Mr.  Shaw  says  :  "  Besides 
causing  a  general  srnallness  of  the  head,  it  will  occasion  a  dis- 
proportion between  the  parts  of  which  it  consists.  As  the  two 
divisions,  the  face  and  the  cranium,  grow  respectively  at  differ- 
ent rates  of  activity,  it  must  follow  that,  when  the  wThole  pro- 
cess is  interrupted  for  a  certain  time,  the  stoppage  will  have  a 
more  decided  effect  upon  the  one  than  upon  the  other ;  upon 
the  division  which  grows  at 'a  rapid  rate  than  upon  that  which 
grows  at  a  more  moderate  rate.  Hence,  as  it  is  the  face  which 
is  developed  in  the  most  active  manner,  and  the  cranium  which 
increases  at  a  slow  rate,  we  may  expect  to  find  that  there  will 
be  a  very  considerable  defect  in  the  size  of  the  face,  and  only  a 
trifling  defect  in  that  of  the  cranium.  In  other  words,  in  per- 
sons whose  growth  has  been  interrupted  by  rickets  the  face  will 
appear  extraordinarily  diminutive,  while  the  cranium  will  re- 
tain about  its  natural  dimensions."  The  effect  of  these  changes 
is,  as  a  general  rule,  to  give,  not  only  the  appearance  of  undue 
size  to  the  head,  but,  from  the  smallness  of  the  face,  the  fore- 
head appears  broad  and  square,  and  often  so  prominent  that 
the  facial  angle  is  very  conspicuously  increased.  This  promi- 
nence of  the  forehead,  when  associated  with  the  precocity  in 
the  mental  faculties,  so  common  a  characteristic  of  rickety  chil- 
dren, gives  the  impression  of  a  finely-developed  head,  and,  con- 
sequently, of  great  intellectual  promise.  Too  much  stress  will 
not  be  laid  upon  these  delusive  appearances,  when  it  is  remem- 
bered that  the  actual  development  of  the  head  is  below  the 
normal  standard,  and  that  precocity  is  apt  to  show  itself  in 
nervous,  excitable,  delicate  children,  from  whatever  cause  this 
bodily  state  may  arise.  One  curious  result  of  Mr.  Shaw's  care- 
ful measurements  relates  to  the  size  of  the  orbital  cavities. 
These  he  found  unvarying  in  their  dimensions,  whatever  might 
be  the  size  of  the  skull.  In  speaking  of  a  table,  in  which  he 
gives  numerous  measurements  of  their  size,  he  says :  "  If  this 
list  be  examined,  by  running  the  eye  along  the  line  of  figures 
which  shows  the  measurements  of  the  orbits,  it  will  be  per- 
ceived that  there  is  scarcely  an  appreciable  difference  between 


68  DISEASES  OF  BONE. 

the  dimensions  of  these  parts  in  any  of  the  skulls.  "Whether 
we  take  the  rickety  skulls,  those  of  standard  size,  or  the  skull 
of  the  giant,  the  diameters  of  the  orbits  measure  the  same  in 
all.  As  they  are  not  below  the  standard  dimensions  in  the 
rickety  specimens,  so  they  are  not  above  them  in  the  giant." 

Fig.  9  is  a  drawing  of  a  specimen,  recently  deposited  by 
Prof.  Humphry  in  the  Anatomical  Museum  of  the  University 
of  Cambridge,  and  gives  a  good  idea  of  most  of  the  changes 


FIG.  9. 


produced  in  the  various  parts  of  the  skeleton  by  this  disease. 
Prof.  Humphry  publishes  a  full  account  of  this  case  in    the 
Journal  of  Anatomy  and  Physiology,  for  November,  1S67. 
In  this  connection,  it  is  proper  to  notice  the  effects  produced 


RICKETS.  69 

by  rickets  on  the  process  of  dentition.  All  the  actions  con- 
nected with  this  process  seem  to  be  imperfectly  accomplished. 
The  evolution  of  the  teeth  begins  late,  it  is  slow  in  being  com- 
pleted, and  the  life  of  the  teeth  is  apt  to  terminate  earty,  either 
by  their  falling  out,  or  by  a  rapidly-destructive  caries.  These 
effects  seem  to  be  produced  by  the  constitutional  weakness, 
which  elaborates,  slowly  and  imperfectly,  the  complex  phases 
of  dentition,  but  perhaps  also,  in  a  very  great  degree,  they  are 
determined  by  the  want  of  proportion  between  the  teeth  and 
the  jaw  in  which  they  grow.  The  teeth  have  their  normal 
size,  the  jaw  has  not,  and  that  gradual  change  by  which,  in  a 
healthy  individual,  the  relative  proportion  between  the  teeth 
and  the  jaw  is  constantly  being  maintained  is,  in  the  rickety, 
materially  checked,  so  that,  as  the  teeth  push  forward  to  the 
surface,  room  is  not  afforded  them,  by  the  proper  expansion  of 
the  jaw-bones,  for  their  emergence  in  the  regular  and  orderly 
manner  on  which  so  much  of  their  usefulness  depends.  Hence, 
we  have  the  teeth  crowded,  irregular,  and  imperfect,  appearing 
above  the  jaw  late  and  slowly,  giving  rise  to  many  painful  and 
sometimes  serious  symptoms,  arising  from  the  mechanical  ob- 
structions against  which  they  have  to  contend,  and  doing  poor 
and  painful  service  while  they  last,  to  be  lost  early,  either  from 
decay  or  from  want  of  a  well-developed  alveolar  base,  on  which 
they  might  be  maintained. 

We  have  now  remaining  two  classes  of  anatomical  lesions 
characteristic  of  rickets,  which  show  themselves,  not  in  the 
bones,  but  in  the  soft  parts.  These  are — 

6.  Certain  Lesions  of  the  Lungs,  Pericardium,  and  Spleen, 
the  Direct  Consequence  of  the  Thoracic  Deformity. — Of  the 
lun^s,  we  have  two  conditions  which  are  abnormal,  viz. :  1.  Em- 

o    /  / 

physema.  2.  Collapse.  These  two  conditions  of  the  lung-sub- 
stance are  both  of  them  evidently  due  to  the  unequal  pressure 
exerted  on  the  lungs  by  the  deformity  of  the  thorax,  and  by 
the  imperfect  action  of  such  a  thorax,  in  accommodating  itself 
to  the  varied  necessities  of  respiration.  Of  the  emphysema, 
Dr.  Jenner  says  it  is  "  that  variety  which  has  been  termed  in- 
sufflation. It  is  mere  over-distention  with  air  of  the  vesicular 
tissue  of  the  lung.  It  invariably  occupies  the  same  situation 
in  the  lungs  of  the  rickety  child,  viz.,  the  whole  length  of  the 


70  DISEASES  OF   BONE. 

anterior  border  of  both  lung?,  extending  backward  for  about 
three-quarters  of  an  inch  from  the  free  margins.  The  emphy- 
sematous  portion  is  separated  from  the  healthy  part  of  the  lung 
by  a  groove  formed  by  collapsed  lung.  The  groove  of  col- 
lapsed tissue  corresponds  to  those  projections  of  the  ribs  inward 
which  are  situated  at  the  points  where  they  unite  with  their 
cartilages."  The  collapse  is  sometimes  confined  to  this  border 
or  groove  above  noticed,  but  it  is  extremely  common  to  h'nd 
large  portions  of  the  posterior  and  inferior  parts  of  the 
lungs  in  a  state  of  collapse,  which  sometimes  extends  to  the 
superior  lobes.  Thus  it  is  a  pathological  fact  of  much  impor- 
tance that,  in  rickety  children,  not  only  do  we  have  imperfect 
formation,  and  diminished  power  of  action  on  the  part  of  the 
thorax,  but  we  have  an  imperfect  condition,  more  or  less  ex- 
tensively pervading  the  lung-substance  itself,  a  fact  which  has 
much  significance  when,  through  stress  of  disease,  unusual  de- 
mands are  made  upon  both  thorax  and  lung,  to  meet  the  re- 
quirements of  increased  aeration,  which  the  affection  of  the 
lungs  imperiously  calls  for.  Besides  these  anatomical  lesions 
of  the  lungs,  authors  notice  certain  white  spots  or  patches  on 
the  surface  of  the  pericardium,  and  on  the  surface  of  the  spleen, 
which  would  seem  to  have  excited  more  attention  than  their 
importance  entitles  them  to.  They  correspond  with  the  points 
where  the  pressure  of  the  deformed  thorax  is  most  constantly 
felt  by  the  organs  affected,  and  are  doubtless  produced  by  the  con- 
stant attrition  of  the  projecting  bone  against  their  serous  surface. 

7.  Important  Changes  affecting  the  Nutrition  of  the  Brain, 
Spleen,  Liver,  Lymphatic  Gland,s,  and  some  other  Organs. — 
These  changes  occur  gradually,  and  without  any  signs  of  inflam- 
mation, and  are  the  evident  expression  of  a  constitutional  cachexia 
which  they  in  their  turn  tend  very  materially  to  aggravate. 

Their  most  common  seat  is  in  the  lymphatic  glands,  which 
are  apt  to  be  extensively,  often  universally,  diseased,  and  with 
them  the  spleen  is  almost  certain  to  be  more  or  le>s  implicated. 
The  other  organs  enumerated  are  less  frequently  the  seat  of 
this  peculiar  change.  The  pathological  state  seems  to  be  one 
in  which  an  infiltration  of  what  Dr.  Jenner  calls  an  albuminoid 
exudation,  throughout  the  substance  of  the  organ,  slowly  takes 
place,  much  after  the  manner  of  infiltrated  tubercle,  which  so 


RICKETS.  71 

thoroughly  incorporates  itself  with  the  substance  of  the  affected 
tissue  that  its  original  texture  is  entirely  lost,  it  assumes  a  fatty 
or  waxy  appearance,  and  loses,  more  or  less  completely,  its 
functional  power.  After  stating  that  the  lymphatic  glands 
thus  affected  are  considerably  enlarged,  Dr.  Jenner  thus  de- 
scribes their  appearance :  "  The  cut  surface  of  the  glands  is 
singularly  pale  and  transparent,  compact,  smooth,  tolerably 
moist,  and,  to  the  unaided  eye,  uniform  in  appearance.  The 
substance  is  tough,  and  the  gland  heavy  in  proportion  to  its 
size.  In  rare  cases,  instead  of  being  pale,  the  glands  may  be 
purplish  in  color."  Of  the  spleen  he  says:  "It  is  increased  in 
size  :  the  increase  may  be  either  trifling  or  extreme.  Thus  I 
have  seen  it  little  larger  than  in  health,  and  I  have  seen  it 
measure  as  much  as  eight  inches  from  above  downward  over 
its  convex  surface,  and  four  inches  from  side  to  side.  It  is 
never  adherent  to  the  parts  adjacent,  as  a  spleen  containing 
tubercles  often  is,  and  its  capsule  generally  is  scarcely,  if  at  all, 
thickened.  Its  anterior  border  is  pretty  sharp ;  it  is  firm  to 
the  touch,  and  smooth  on  the  surface ;  its  weight,  regard  being 
had  to  its  size,  strikes  one  as  considerable.  The  substance  is 
tough  but  elastic,  and  the  thinnest  sections  can  be  cut  with 
facility.  The  cut  surface  is  remarkably  smooth  and  transparent. 
It  is  not  unlike  what  one  might  suppose  would  be  its  appear- 
ance if  the  whole  organ  were  infiltrated  with  glue.  Only  a 
little  pale  blood  can  be  expressed  from  the  cut  surface.  Usually, 
the  organ  is  pale  red,  but  occasionally  it  is  dark  purple.  The 
more  transparent  any  given  part  is,  the  paler  it  is ;  the  most 
transparent  parts  are  almost  colorless.  The  splenic  corpuscles 
are  sometimes  more  readily  seen  than  in  a  healthy  spleen  ;  they 
may  be  mistaken  for  gray  tubercles.  I  have  never  seen  in  the 
spleen  of  rickety  children  the  sago-like  little  masses,  so  often 
present  in  the  spleens  of  those  who  die  of  phthisis." 

With  this  anatomical  change  in  these  organs,  and  very 
much  in  proportion  to  its  extent,  we  have  the  constitutional 
cachexia  becoming  more  marked  and  more  distinctly  progres- 
sive. Emaciation  is  sometimes  extreme,  muscular  power  grows 
gradually  less  and  less,  the  derangements  of  digestion  become 
more  and  more  constant,  and  the  little  patient  either  wastes 
gradually  away,  or  succumbs  to  the  attack  of  bronchial  or  in- 


72  DISEASES  OF  BONE. 

testinal  inflammation,  whose  effects  his  weakened  organization 
is  not  able  to  contend  with.  Dr.  Jenner  thinks  that  the  most 
common  cause  of  death  in  rickets  is  acute  bronchitis,  and 
explains  its  fatality  by  the  imperfect  action  of  the  soft  and 
yielding  walls  of  the  thorax.  He  also  says  what  seems  very 
astonishing,  that  to  rickets  is  due,  in  London,  directly  or  indi- 
rectly, a  larger  percentage  of  infantile  mortality  than  can  be 
credited  to  any  other  single  disease. 

"With  regard  to  the  causes  of  rickets,  nothing  very  positive 
has  been  ascertained.  It  is  very  certain  that  it  prevails  prin- 
cipally among  the  poor,  though  it  is  sometimes  seen  in  the 
children  of  the  rich.  Its  prevalence  is  certainly  favored  by 
bad  hygienic  surroundings,  but  the  same  may  be  said  of  every 
diathetic  disease ;  and  why  these  unfavorable  conditions  should 
produce  in  one  region  rickets,  and  in  another  scrofula,  as  a 
preponderating  disease  among  the  infantile  population,  does 
not  seem  clear.  It  has  been  pretty  distinctly  shown  that  it  is 
not  hereditary,  and  yet,  when  one  child  in  a  family  has  the 
disease,  those  born  afterward  are  extremely  apt  to  show  traces 
of  it.  Dr.  Jenner  thinks  that  the  state  of  health  of  the  mother 
has  much  to  do  with  the  occurrence  of  rickets  in  the  children ; 
if  she  be  feeble,  delicate,  ill  nourished,  and  ill  cared  for,  she 
will  be  much  more  likely  to  have  rickets  in  her  children  than 
if  she  were  strong  and  robust  in  her  own  health.  Phthisis  and 
rickets  have  no  necessary  connection.  Statistics  show  that 
phthisical  parents  are  no  more  liable  to  have  rickety  offspring 
than  those  who  are  not  phthisical ;  and  it  appears  that  scrofula, 
the  twin-sister  of  tuberculosis,  is  not  by  any  means  commonly 
associated  with  rickets  in  the  same  individual.  Bad  food,  bad 
air,  bad  clothing,  bad  habits  of  life,  and  exposure — in  short,  all 
those  circumstances  which  are  generally  combined  in  the 
miserable,  crowded,  filthy  habitations  of  the  poor,  and  which 
so  manifestly  affect  the  general  mortality  of  the  districts  where 
these  habitations  are  crowded  together — all  these  have  an  un- 
doubted influence  in  producing  the  disease  ;  and  this  is  more 
practically  interesting  because  it  is  in  this  direction  that  we 
must  look  for  our  principal  means  of  controlling  and  curing  it. 
In  fact,  the  treatment  of  rickets,  as  such,  is  entirely  unsatisfac- 
tory ;  and  the  very  natural  idea,  that,  by  supplying  an  excess 


RICKETS.  73 

of  earthy  matter  to  the  stomach,  we  should  cure  a  disease  char- 
acterized mainly  by  its  deficiency,  has  not  proved  in  practice 
to  be  well  founded.  Not  only  is  there  no  specific  for  rickets, 
but  there  is  no  specific  treatment.  Every  case  must  be  studied 
by  itself,  and  managed  on  the  general  principles  of  constitu- 
tional treatment.  The  first  cares  are  hygienic.  Improve  as  far 
as  may  be  the  home  and  the  habits ;  and,  of  these,  none  are  so 
important  as  the  habits  with  regard  to  food.  The  children  of 
the  poor  are  always  fed  improperly.  Even  with  those  who  are 
industrious  and  thriving,  and  who,  therefore,  have  the  means 
of  supplying  a  sufficiency  of  good  food  to  their  families,  we 
constantly  find  the  younger  children,  particularly  the  infants 
of  from  one  to  two  years  of  age,  fed  on  food  too  stimulating 
for  their  stomachs.  There  seems  to  be  in  the  minds  of  these 
people  a  kind  of  pride  in  seeing  their  babies  sitting  at  the 
table  with  them,  and,  even  before  they  are  weaned,  partaking 
of  the  strong  food  which  makes  their  parents'  ordinary  fare. 
It  requires  some  time,  much  care,  and  some  trouble,  to  prepare 
the  milk-food  which  should  be  the  principal  food  of  every 
child  under  two  years  of  age.  From  these  two  considerations 
arises  the  habit,  almost  universal,  of  giving  the  children  what- 
ever they  like  to  eat,  and  rather  letting  them  feed  themselves, 
than  taking  any  pains  to  provide  or  prepare  for  them  food  such 
as  shall  be  suitable  for  the  digestive  power  of  their  tender 
stomachs.  This  is  undoubtedly  a  common  cause  of  disease 
among  the  poor.  The  strong  bear  it,  while  the  feeble  die 
under  it.  In  rickets  there  is  so  marked  a  tendency  to  de- 
rangement of  the  digestive  organs,  that  it  would  seem  that  the 
regulation  of  the  food  was  a  point  of  even  more  than  usual 
importance,  and  its  proper  quantity  and  quality  a  prime  sub- 
ject for  the  watchfulness  of  the  physician.  After  the  care  of 
the  food  comes  that  of  the  air,  the  exercise,  the  clothing,  the 
cleanliness,  and  the  hundred  other  things  which  go  toward  the 
making  of  good  blood  and  strong  muscle.  In  the  regulation 
of  many  of  these  points  much  can  be  done,  for  it  must  be 
remembered  that  a  large  proportion  of  the  errors  committed 
in  these  respects  arise  much  more  from  ignorance  and  inatten- 
tion than  from  actual  poverty. 

In  regard  to  medication,  the  main  indication  is  to  improve 


74  DISEASES  OF  BONE. 

nutrition.  Tonics,  such  as  iron,  and  cod-liver  oil,  are  most 
commonly  useful,  and  spoliative  and  depressing  treatment, 
such  as  is  usually  called  the  antiphlogistic,  is  badly  borne. 
Particular  caution  is  required  in  managing  the  acute  affections, 
which  so  frequently  supervene  in  the  course  of  rickets,  that 
too  much  reduction  of  the  powers  of  life  be  not  produced  by 
the  very  remedies  we  use  to  save  it.  Mercury  and  bloodlet- 
ting are  both  reprobated  as  dangerous  by  the  best  authorities, 
and  the  care  of  the  practitioner  should  be  to  accomplish  his 
ends  with  the  mildest  means  compatible  with  success.  Each 
case  and  each  complication  must  be  judged  by  itself,  and 
treated  both  hygienically  and  medicinally,  according  to  its  own 
indications;  but,  in  all,  the  one  main  fact  must  be  constantly 
kept  in  view,  that  we  are  dealing  with  a  diathetic  disease,  and 
one  whose  tendencies  are  all  toward  a  feeble  reaction,  and  a 
diminished  reparative  power. 


CHAPTER  VII. 

MOLLITIES   OSSIUM — MALACOSTEON. 

A  CERTAIN  number  of  cases  present  themselves  in  the  adult, 
in  which  a  softening  of  the  bones  takes  place  somewhat  like  the 
softening  of  rickets,  but  in  which  the  accompanying  features 
do  not  warrant  us  in  placing  the  disorder  in  that  class.  These 
cases  are  quite  rare,  and  are  scattered  over  the  records  as  indi- 
vidual cases  by  single  observers,  few  writers  having  had  an 
opportunity  of  observing  any  number  of  them,  and  none,  there- 
fore, having  had  that  kind  of  experience  which  can  only  arise 
from  a  comparison  of  many  examples  of  a  givqn  disease.  From 
these  recorded  cases  the  general  history  of  the  disease  may  be 
gleaned,  and  yet,  so  considerable  are  the  diversities  of  charac- 
ter among  the  individual  cases,  that  it  is  difficult  to  present  a 
clear  picture  of  the  affection,  such  as  can  be  recognized  by  its 
own  characteristics,  and  distinguished  easily  from  other  disor- 
ders to  which  it  is  closely  related. 

The  cases  thus   far  observed  have  occurred  in  young  or 


MOLLITIES   OSSIUM— MALACOSTEON.  75 

middle-aged  adults,  a  little  more  frequently  among  females 
than  among  males,  and  so  often  in  connection  with  the  puer- 
peral state  as  to  warrant  the  opinion  that  this  state  is  at  least 
a  strong  predisposing  cause  of  the  disease.  In  a  few  instances 
it  has  seemed  to  be  transmitted  from  parent  to  child.  With 
these  exceptions  very  little  is  known  of  the  cause  of  the  dis- 
ease. 

The  changes  that  take  place  in  the  bone  seem  to  vary  con- 
siderably, both  in  their  nature  and  in  their  extent,  in  different 
cases.  In  all,  however,  a  gradual  diminution,  and  in  some  an 
entire  disappearance  of  the  earthy  salts  of  .the  bone,  takes  place ; 
a  change  upon  which,  of  course,  the  main  features  of  the  dis- 
ease depend.  This  change  takes  place  gradually,  and  invades 
more  or  less  completely  all  the  bones  of  the  skeleton.  In  some 
cases  this  loss  of  the  earthy  constituents  seems  to  be  almost 
the  only  change  which  takes  place,  the  remaining  animal  sub- 
stance not  having  undergone  any  very  marked  alteration.  In 
other,  and  much  the  larger  number  of  instances,  marked  de- 
generation of  all  the  component  elements  of  the  bone-tissue  is 
found.  Thus  the  original  structures  'are  often  replaced  by  fat 
or  free  oil,  and  this  is  so  common  a  feature  that  Mr.  Paget  is 
inclined  to  regard  the  affection  as  essentially  a  fatty  degenera- 
tion. This  fatty  change  involves  the  whole  bony  substance, 
and,  when  excessive,  converts  the  bone  into  a  bag  of  soft,  oily 
substance,  enclosed  in  the  periosteum,  which  itself  may  not  be 
materially  altered  from  the  healthy  condition.  That  it  is  not 
a  fatty  degeneration  in  all  cases,  however,  is  shown  by  certain 
examples  where  the  replacing  material  is  of  a  gelatinous  nature 
and  presents  few  or  no  traces  of  fat,  and  certain  others  where 
the  amount  of  fat  in  the  bone  does  not  vary  from  its  normal 
proportion.  The  change  in  the  bone  sometimes  involves  the 
compact  and  the  .cancellous  structures  equally  in  its  progress, 
and  when  this  is  the  case  there  is  a  gradual  diminution  of  the 
firmness  of  its  texture,  which  permits  it  to  bend  instead  of  sus- 
taining mechanical  force.  This  flexile  condition  of  bone  is 
sometimes  found  to  the  most  marvellous  degree,  and  in  all  the 
bones  of  the  skeleton,  and  it  seems  to  depend  for  its  produc- 
tion upon  the  evenness  of  the  process  in  all  parts  of  the  bone 
at  once.  Sometimes,  however,  it  happens  that  the  central  can- 


76  DISEASES   OF  BONE. 

cellous  portions  are  far  advanced  in  the  degenerative  changes, 
while  the  external  compact  shell,  yielding  more  slowly,  is  only 
thinned  and  weakened,  but  not  yet  disorganized.  In  this  con- 
dition the  bone  does  not  bend  so  readily  as  it  breaks,  and  we 
have  produced  sometimes  one  and  sometimes  many  fractures, 
arising  from  so  slight  a  force  as  almost  to  seem  spontaneous. 

The  microscopic  study  of  the  altered  bone  shows  so  very 
different  appearances  in  different  cases  that  it  can  hardly  be 
said  that  any  thing  distinctive  has  been  discovered  which  char- 
acterizes osteomalacia  as  contrasted  with  rickets.  Still  the 
general  features  of  this  disease,  as  displayed  by  the  microscope, 
are  not  the  same  as  those  of  rickets.  Follin  says :  "  The  alter- 
ations in  this  case  are  very  different  from  those  which  are  es- 
tablished as  belonging  to  the  rickets  of  children.  Thus,  in  the 
osseous  layers  of  recent  formation,  we  find  an  alteration  in  the 
bone-corpuscles,  which  have  become  elongated,  fusiform,  and 
without  regular  borders,  and  have  taken  on  the  character  of 
the  elements  of  fibrous  tissue.  More  deeply  we  observe  bone- 
cells  which  have  become  irregular,  enlarged,  with  shining  out- 
line, and  with  a  disappearance  of  their  canaliculi ;  they  con- 
tain sometimes  small  drops  of  oil,  and  sometimes  granulations 
grouped  together.  The  fundamental  substance  of  the  bone 
presents  an  infiltration  of  fatty  granulations,  which  impairs  its 
transparency  and  gradually  invades  the  surrounding  parts.  The 
Haversian  canals  are  also  infiltrated.  Thus,  when  we  examine 
by  the  microscope  a  section  of  one  of  these  Haversian  canals, 
we  see  in  the  centre  a  darkish  part  formed  by  a  mass  of  blood- 
globules,  and  around  this  mass  a  cavity  with  distinct  borders, 
filled  with  little  drops  of  oil,  with  fatty  granulations,  and  with 
marrow-cells  in  process  of  formation.  In  the  medullary  tissue 
we  find  hypertrophy  of  the  marrow-cells  and  an  increase  in 
their  number,  as  is  also  the  case  with  the  fatty  cells."  Mr. 
Dalrymple,  in  a  case  which  he  examined,  found  some  peculiar 
caudate  cells,  which  induced  him  to  regard  the  disease  as  ma- 
lignant in  its  essential  characters,  and  other  observers  have 
given  accounts  varying  in  many  points  from  those  given  above. 
It  would  seem,  therefore,  that  the  microscopical  appearances 
vary  with  the  other  peculiarities  of  each  case,  and  that  thus  far 
no  features  can  be  said  to  be  absolutely  characteristic. 


MOLLITIES   OSSIUM— MALACOSTEON.  77 

The  symptoms  of  this  disease  seem  to  be  more  uniform  than 
the  pathological  appearances.  In  the  earlier  stages,  the  pa- 
tients complain  of  vague,  wandering  pains,  at  first  not 
severe,  increased  very  much  by  exercise,  and  accompanied  by 
a  distressing  sense  of  weariness,  which  is  but  little  relieved  by 
rest.  These  pains  are  sometimes  periodical,  and  often  accom- 
panied, particularly  after  exercise,  with  severe  cramps.  Writers 
speak  also  of  a  tenderness  and  soreness  to  the  touch  which 
much  aggravates  the  sufferings  of  the  patient.  As  these  symp- 
toms advance,  the  general  state  of  the  patient  deteriorates. 
He  becomes  feeble,  emaciates,  and  begins  to  have  irregular 
fever,  followed  by  very  copious  and  exhausting  sweats.  The 
digestive  power  begins  to  fail,  a  change  very  much  hastened 
by  the  condition  of  the  teeth,  which  soon  become  so  loose  in 
their  sockets,  from  the  softening  of  the  alveolar  processes,  that 
they  either  drop  out,  or  give  infinite  inconvenience  and  dis- 
comfort in  the  attempt  to  masticate.  Of  course,  when  the 
softening  of  the  thorax  has  reached  an  extreme  degree,  the 
function  of  respiration  must  be  imperfectly  performed,  and  an- 
other serious  embarrassment  is  added  to  the  load  already  press- 
ing so  heavily  on  the  powers  of  life.  The  termination  of  much 
the  largest  number  of  cases  is  fatal,  after  a  longer  or  shorter 
course  of  suffering ;  but  a  certain  number  of  recoveries  are  re- 
ported by  various  authors,  and  in  particular  Naegele  cites  a 
case  in  which  the  Caesarean  section  was  performed  on  a  woman 
whose  pelvis  was  so  deformed  by  an  attack  of  osteomalacia 
that  natural  delivery  was  impossible.  Other  recoveries  are  also 
spoken  of,  in  which  the  deformities  produced  by  the  softened 
state  of  the  bone  remained  permanently  impressed  upon  them. 

During  the  course  of  this  disease,  the  most  striking  symptoms 
are  due  to  the  mechanical  results  of  the  yielding  of  the  soft- 
ened bones.  The  lower  extremities  are  bent  and  twisted  in  the 
most  remarkable  manner,  and,  after  the  patients  are  bedrid, 
the  upper  extremities,  upon  which  they  now  have  to  depend 
for  movements  of  all  kinds,  begin  also  to  be  distorted.  The 
cranial  vault  sometimes  undergoes  a  change,  being  either  flat- 
tened by  compression,  or  rounded  by  the  weight  of  the  brain ; 
but  these  changes  are  pronounced  to  be  very  rare.  The  spine 
is  deformed  mainly  by  an  increase  of  its  natural  curves,  and 


78  DISEASES   OF  BONE. 

the  changes  in  the  thorax  are  clue  mainly  to  the  position  of  the 
patient  in  the  bed.  If  he  lie  constantly  on  his  back,  the  an- 
tero-posterior  diameters  are  diminished,  and  the  chest-cavity 
becomes  broader  laterally  and  shallower  from  before  backward. 
If,  on  the  other  hand,  he  lie  habitually  on  his  side,  the  change 
in  the  form  of  the  chest  becomes  marked  by  an  antero-poste- 
rior  increase,  and  a  lateral  diminution  in  diameters,  together 
with  such  other  deformity  as  the  twisted  position  of  the  spine 
may  impress  upon  it.  In  the  pelvis,  these  changes  are  very 
marked,  and  have  been  particularly  studied.  We  have  al- 
ready seen  how  the  form  of  the  pelvis  is  affected  by  rickets. 
In  malacosteon,  the  deformity  presents  features  so  different 
that  writers  contend  that  the  disease  can  be  distinguished  by 
the  deformity ;  rickets  exercising  its  effects  mainly  by  a  dimi- 
nution of  the  antero-posterior  diameters,  while  osteomalacia 
usually  produces  a  contraction  of  the  pelvic  circles  in  a  lateral 
direction.  This  distinction,  however,  is  not  to  be  relied  on  too 
implicitly,  for  several  authors  speak  of  cases  in  which  rickets 
produced  a  lateral  deformity  precisely  similar  to  that  ordinarily 
resulting  from  osteomalacia.  The  general  fact,  however,  re- 
mains, that  in  malacosteon  the  deformity  is  produced  by  the 
yielding  of  the  sides  of  the  pelvis.  Dr.  Tyler  Smith  thus  sums 
up  these  changes :  "  The  general  effects  produced  in  malacos- 
teon are :  narrowing  of  all  the  diameters  of  the  pelvis,  but  es- 
pecially of  the  transverse,  whether  of  the  brim,  cavity,  or  out- 
let. The  antero-posterior  diameter  of  the  brim,  or  rather,  the 
distance  from  the  promontory  of  the  sacrum  to  the  symphysis 
pubis,  is,  relatively  to  the  transverse  diameter,  very  much  in- 
creased ;  absolutely  it  is  somewhat  less  than  natural.  The 
pubic  arch  is  very  much  narrowed  ;  the  tuberosities  of  the  ischia 
are  approximated ;  the  sacrum  is  very  much  incurvated,  and 
the  acetabula  are  much  closer  together  than  in  the  normal  pel- 
vis ;  the  ilia,  instead  of  being  carried  bodily  forward,  as  in  the 
rickety  pelvis,  are  folded  up,  and  the  iliac  fossa  is  made  to  re- 
semble an  oblique  furrow,  running  from  above  downward." 
Dr.  Matthews  Duncan,  in  a  paper  published  in  the  Edinburgh 
Monthly  Journal  for  April,  1855,  has  very  carefully  compared 
these  deformities  with  one  another,  and  gives  a  series  of  in- 
genious diagrams,  by  which  he  illustrates,  by  accurate  measure- 


MOLLITIES   OSSIUM— MALACOSTEON.  79 

ment,  the  difference  produced  on  the  absolute  and  relative 
diameters  by  the  two  diseases.  His  demonstrations  are  very 
full  and  clear,  and  minutely  establish  the  difference  in  the  effect 
of  the  two  diseases  on  the  form  of  the  pelvis — a  difference,  the 
general  features  of  which  are  sufficiently  expressed  in  the  state- 
ments made  above. 

The  urine,  in  malacosteon,  has  sometimes  presented  marked 
alterations  in  quality  and  appearance,  and  several  of  the  ear- 
liest writers  have  recorded  cases  where  it  deposited  a  copious 
sediment  of  a  white,  chalk-like  substance,  sometimes  described 
as  a  mortar-like  material  on  cooling,  or  after  •  evaporation. 
Later  and  more  thorough  observations  have  shown  this  sub- 
stance to  be  mainly  phosphate  of  lime,  and  the  idea  was  natu- 
rally suggested  that  this  might,  therefore,  throw  some  light  on 
the  pathology  of  the  disease ;  the  waste  of  the  bone-earths 
through  the  kidneys  explaining  very  satisfactorily  their  disap- 
pearance from  the  bones  where  they  properly  belong.  This 
renal  view  of  the  pathology  of  malacosteon,  though  so  promis- 
ing, has  not  borne  the  test  of  larger  experience;  and  it  is 
found  that,  in  a  certain  proportion  of  the  cases,  there  is  at  no 
time  any  change  in  the  urine  which  will  in  anyway  correspond 
to  the  changes  in  the  bones  ;  in  fact,  that  there  is,  in  some  cases, 
no  deviation  whatever  from  the  healthy  constitution  and  ap- 
pearance of  the  renal  secretion.  Still,  though  the  urine  may 
not  have  supplied  a  key  to  the  real  pathology  of  malacosteon, 
its  changes  in  this  disease  are  certainly  worthy  of  careful  con- 
sideration, and  we  can  hardly  regard  as  merely  accidental, 
phenomena  which  present  themselves  in  certainly  the  larger 
proportion  of  cases  thus  far  recorded.  Besides  the  more  nu- 
merous cases  in  which  an  excess  of  phosphates  has  been  found 
in  the  urine,  there  are  some  where  other  substances  have  been 
discovered  which  did  not  belong  to  its  healthy  condition.  Thus 
Mr.  Dalrymple  reports  a  case  on  which  Dr.  Bence  Jones  made 
some  observations  in  the  "  Philosophical  Transactions,"  vol. 
Ixvi.,  in  which  he  shows  that  the  peculiar  matter  in  the  urine 
which  Mr.  Dalrymple  had  described  was,  in  fact,  a  deutoxide 
of  albumen,  combined  with  water  so  as  to  form  a  hydrate.  Dr. 
Jones  says :  "  There  was  as  much  of  this  peculiar  albuminous 
substance  in  the  urine  as  there  is  of  ordinary  albumen  in  the 


80  DISEASES  OF  BONE. 

blood.  So  far,  then,  as  the  albumen  is  concerned,  each  ounce 
of  urine  passed  was  equivalent  to  an  ounce  of  blood  lost.  The 
peculiar  characteristic  of  this  hydrated  deutoxide  of  albumen 
was  its  solubility  in  boiling  water,  and  the  precipitate  with 
nitric  acid  being  dissolved  by  heat,  and  reformed  when  cold, 
by  this  reaction,  a  similar  substance  in  small  quantities  may  be 
detected  in  pus,  and  in  the  secretion  from  the  vesiculae  semi- 
nales.  This  substance  must  be  again  looked  for  in  acute  cases 
of  mollities  ossium.  The  reddening  of  the  urine  on  the  addi- 
tion of  nitric  acid  might,  perhaps,  lead  to  the  rediscovery  of  it. 
When  found,  the  presence  of  chlorine  in  the  urine  (of  which 
there  was  a  suspicion  in  the  above  case)  should  be  a  special  sub- 
ject of  investigation,  as  it  may  lead  not  only  to  the  explanation 
of  the  formation  of  this  substance,  but  to  the  comprehension 
of  the  nature  of  the  disease  which  affects  the  bones."  Mr. 
Erichsen  refers  to  the  analysis  of  the  urine,  in  a  case  of  Dr. 
Mclntyre's,  published  in  the  "  Medico-Chirurgical  Transac- 
tions," vol.  xxxiii.,  in  which  an  animal  substance,  differing  in 
most  of  its  chemical  reactions  from  albumen,  was  found  in  the 
urine  in  great  abundance. 

In  illustration  of  the  general  features  and  course  of  this 
singular  disease,  I  add  a  sketch  of  the  famous  case  of  Madame 
Supiot,  one  of  the  most  remarkable,  and  probably  the  best 
known,  of  any  on  record  : 

Elizabeth  Querian — afterward  Supiot — came  under  obser- 
vation in  the  year  1752.  She  was  then  thirty-six  years  of  age. 
She  had  had  three  children  and  one  miscarriage,  without  any 
serious  accident.  She  had  twice  had  falls,  which  produced 
more  than  usual  swelling  and  lameness  of  the  limb  injured, 
but  no  fracture.  She  had  had,  however,  much  aching  pain  in 
her  extremities,  and  of  late  had  not  been  able  to  sustain  her- 
self on  her  feet  without  suffering.  She  had  now  been  bedrid 
from  this  cause  about  two  years.  About  a  year  before — that 
is,  in  1751 — she  had  commenced  to  observe  a  milky  sediment 
in  the  urine,  and  about  the  same  time  the  bones  began  to 
show  some  evidences  of  softening,  and  the  legs  to  assume  a 
distorted  position  from  the  retraction  of  the  muscles.  This 
was  accompanied  by  a  very  great  increase  of  the  pains  in  the 
limbs,  which  at  times  were  intolerable.  At  first  sight,  the 


MOLLITIES   OSSIUM— MALACOSTEON.  Rl 

woman,  as  she  lay  in  bed,  seemed  to  have  neither  feet  nor  legs 
nor  hands.  It  seemed  that  the  body  terminated  at  the  pubis. 
The  thigh-bone  had  curved  so  as  to  allow  the  foot  and  the  leg 
to  turn  up  by  the  side  of  the  body,  so  that  the  left  leg  inclined 
to  be  under  the  back,  and  she  could  on  this  side  lay  her  head 
on  her  foot.  The  right  thigh-bone  was  similarly  bent,  and  the 
whole  extremity  drawn  forcibly  against  the  right  side  of  the 
body.  The  patient  could  not  move  herself  in  bed.  Defecation 
and  urination  were  not  interfered  with.  This  violent  separa- 
tion and  twisting  of  the  thighs,  however,  caused  sufficient 
pressure  on  the  crural  vessels  to  interfere  in  some  degree  with 
their  free  circulation  of  the  blood,  and  consequently  some 
oedematous  swelling  of  both  limbs  existed.  The  thorax,  sink- 
ing down  at  certain  points  upon  the  lungs,  interfered  with  res- 
piration, and  at  times  she  spat  some  blood.  The  upper  part  of 
the  sternum  was  prominent,  the  lower  part  sunken  in.  The 
clavicles  were  more  than  usually  prominent  at  their  sternal  ex- 
tremity. The  humerus  was  curved  about  its  middle  from  with- 
in outward,  as  well  as  the  forearm,  so  that  the  middle  part  of 
the  right  arm  was  habitually  applied  against  the  internal  mal- 
leolus  of  that  side,  while  the  middle  of  the  left  arm  rested  on 
the  upper  part  of  the  tibia,  just  below  the  patella.  She  could 
make  110  use  whatever  of  her  limbs,  being  able  to  move  only 
her  head  and  the  left  arm.  She  could  also  separate  some  of 
her  fingers  slightly,  but  could  not  bend  any  of  them  in  the 
slightest  degree.  The  right  hand  much  atrophied.  Her  teeth 
were  discolored  and  loose,  and  the  gums  swollen  and  ulcerated. 
When  an  attack  of  pain  came  on,  she  often  had  severe  fever, 
followed  by  profuse  sweats,  which  were  apt  to  be  followed  by 
the  eruption  of  papules  or  pimples,  which  caused  very  distress- 
ing itching.  Her  menstruation  was  regular,  but  was  exceed- 
ingly apt  to  be  accompanied  by  very  serious  exaggeration  of 
her  other  disorders  and  sufferings. 


82  DISEASES  OF  BONE. 

CHAPTEK  VIII. 

FRAGILITA8    OSSITTM. 

A  WEAKENING  of  the  texture  of  the  bones,  rendering  them 
more  than  usually  liable  to  be  broken  from  slight  causes,  is 
found  to  occur  in  the  course  of  several  very  different  diseases 
of  the  bone-tissue.  Thus  we  have  seen  that  certain  conditions 
of  malacosteon  present  great  fragility  of  the  bones,  while  it  is 
well  known  that  carcinomatous  infiltration  will  sometimes  so 
weaken  them  that  fracture  occurs  on  the  slightest  possible  prov- 
ocation. Several  instances  are  recorded  where,  both  in  mala- 
costeon, and  in  cancer,  the  thigh-bone  has  snapped  asunder 
from  turning  in  bed,  and  the  arm-bone  from  an  attempt  to 
raise  the  body  in  bed  on  the  elbow.  But,  besides  these  cases, 
there  are  certain  individuals  in  whom,  with  all  the  evidences 
of  good  health,  we  have  a  degree  of  brittleness  of  the  bones 
which  exposes  them  in  a  remarkable  degree  to  the  occurrence 
of  fracture,  and  in  whom  fractures  take  place  from  the  most 
trivial  causes.  I  had  under  my  care,  some  years  ago,  a  gentle- 
man, then  in  middle  life,  who  had  from  various  accidents  seven 
times  fractured  one  or  both  bones  of  the  forearm,  and  on  one 
of  these  occasions  the  fracture  was  produced  by  somewhat  too 
cordial  a  shake  of  the  hand.  This  gentleman  was  rather  slender 
in  his  formation,  with  small  hands  and  feet,  and  delicate  limbs, 
but  was  always  a  healthy  and  active  man,  and  the  father 
of  a  large  family  of  well-formed  children,  none  of  whom  pre- 
sented any  trace  of  this  peculiarity  of  their  parent.  A  gentle- 
man of  our  profession,  who  has  practised  many  years  in  this 
city,  has  twice  fractured  his  leg  by  a  slight  stumble  in  passing 
along  the  street.  He  also  has  the  slight  frame  and  delicate 
formation  which  characterize  the  female,  bat  Ii3  was,  at  the 
time  of  receiving  his  injuries,  in  excellent  health.  He  has 
since  suffered  severely  from  rheumatism.  Mr.  Stanley  alludes 
to  a  case  under  the  care  of  Mr.  Arnott,  in  the  Middlesex  Hos- 
pital, where,  "  in  a  female,  aged  fourteen,  the  first  fracture 
-occurred  at  the  age  of  three  years ;  altogether  there  were 


FRAGILITAS  OSSIUM.  83 

thirty-one  fractures  in  different  bones,  and  in  some  of  them  the 
fracture  was  many  times  repeated.  Many  of  the  fractures 
occurred  from  the  slightest  effort,  and  there  was  no  difficulty 
in  obtaining  their  union.  In  a  sister  of  this  patient,  six  years 
of  age,  there  was  the  same  condition  of  the  bones,  favoring 
the  occurrence  of  fractures.  She  had  suffered  nine  fractures 
since  the  age  of  eight  months."  Other  writers  speak  of  this 
peculiarity  as  belonging  to  several  members  of  the  same  family, 
and  there  are  certain  cases  in  which  its  hereditary  character  is 
unquestionable.  An  instance  is  mentioned  by  Dr.  Pauli,  of 
Leipsic,  in  which,  for  three  generations,  certain  individuals 
of  a  family  have  suffered  from  extraordinary  fragility  of  the 
bones. 

These  cases  are  such  as  appear  to  be  unconnected  with  any 
disease  of  the  bone,  or  any  constitutional  disorder,  the  patient 
enjoying  a  good  degree  of  health,  and  capable,  ordinarily,  of 
fulfilling  the  duties  of  life  in  a  satisfactory  manner.  There 
are  others,  however,  in  which  some  symptoms  precede  the  con- 
dition of  fragility,  and  these  symptoms  are  generally  rather 
vaguely  spoken  of  as  chronic  rheumatism.  Thus  Mr.  Stanley 
reports  the  case  of  a  woman,  aged  twenty-six,  who  was  admit- 
ted into  St.  Bartholomew's  Hospital,  with  a  fracture  of  the  left 
femur.  "  She  stated  that  she  had  suffered  rheumatism  in  this 
limb,  and  that,  three  days  previously,  the  fracture  occurred  as 
she  was  crossing  a  road.  She  was  placed  on  her  back,  with  a 
straight  splint  on  the  outside  of  the  limb.  When  she  had  been 
in  the  hospital  about  two  months,  while  lying  perfectly  quiet 
in  bed,  she  suddenly  cried  out  that  she  felt  a  severe  pain  in  the 
other  thigh,  and  that  the  bone  had  broken.  The  house-surgeon 
happening  to  be  in  the  ward,  found  the  right  femur  fractured 
in  its  centre.  At  subsequent  and  distant  periods,  while  con- 
fined in  bed,  a  second  fracture  of  the  left  femur  occurred,  a 
little  above  the  knee,  and  fractures  of  both  tibiae,  immediately 
below  their  tuberosities.  She  remained  in  the  hospital  above 
two  years,  during  which  every  effort  was  made  to  obtain  the 
union  of  the  fractures.  Throughout  her  general  health  was 
unimpaired,  the  appetite  good,  bowels  regular,  and  the  urine 
perfectly  natural.  At  the  expiration  of  two  years  from  the 
occurrence  of  the  first  fracture,  the  patient  left  the  hospital, 


84  DISEASES   OF   BONE. 

both  lower  limbs  being  powerless,  and,  when  moved,  severely 
painful.  None  of  the  fractures  had  united,  arid  both  limbs 
were  shortened  to  the  extent  of  several  inches,  with  consider- 
able distortion."  In  another  case  mentioned  by  Mr.  Stanley, 
the  symptoms  were  very  similar,  excepting  that  the  patient's 
health  gradually  broke  down,  and  she  suffered  constantly  witli 
general  weariness  and  aching  in  the  bones.  She  died  about 
four  months  after  the  first  fracture.  "  A  portion  of  the  re- 
cently-fractured femur  exhibits  a  thinning  of  its  walls  from 
the  absorption  of  its  inner  laminae,  but  without  softening  of 
its  texture ;  it  retains  the  hardness  of  healthy  bone."  A  man 
was  received  into  the  New  York  Hospital  a  few  years  ago  who 
had  received  a  fracture  of  the  clavicle  from  a  very  trivial  cause. 
He  told  us  that  he  had  been  suffering  for  some  weeks  with 
rheumatic  pain,  and  great  tenderness  about  the  bone,  for  which 
he  could  give  no  explanation.  His  general  health  was  good, 
and  he  had  no  syphilitic  history.  The  bone  was  found  broken 
near  its  middle,  and  was  exceedingly  sensitive  to  the  touch. 
This  was  not  confined  to  the  point  of  fracture,  but  extended 
along  the  whole  clavicle,  which  was  manifestly  thickened 
through  all  its  middle  portions.  The  limb  was  dressed  in  the 
usual  way,  and  the  only  uncommon  feature  noticed  during  the 
progress  of  the  cure  was  that  an  unusual  amount  of  bony 
matter  seemed  to  be  thrown  out,  forming  apparently  a  thick 
ferule  of  callus  around  the  fractured  ends.  He  was  put  upon 
the  use  of  full  doses  of  the  iodide  of  potassium,  and,  when  he 
left  the  hospital,  the  fracture  was  united,  but  the  bone  re- 
mained considerably  enlarged,  and,  very  tender  upon  pressure. 
"With  regard  to  the  result  of  fracture  in  these  cases  of  fra- 
gility of  the  bones,  it  seems  to  be  different  in  the  two  classes 
of  cases.  In  those  where  no  disease  exists,  and  where,  there- 
fore, the  pathology  of  the  case  may  be  considered  to  be  a  mere 
delicacy  and  slenderness  of  construction  of  the  bone,  it  seems 
to  be  generally  conceded  that  we  may  hope  for  a  very  rapid 
and  very  perfect  cure.  Indeed,  it  would  seem  that  the  ease 
of  the  cure  bore  some  proportion  to  the  facility  of  the  fracture; 
many  of  these  patients  being  reported  as  having  much  less  suf- 
fering and  trouble  during  the  union  of  their  fractures  than  oc- 
cur in  ordinary  cases.  In  many  of  the  cases,  however,  when 


TUBERCULAR  DISEASE  OF  BONE.  85 

the  rheumatic  pains,  showing  diseased  action  about  the  bones, 
had  existed  in  a  marked  degree  and  for  a  considerable  period 
of  time,  the  sufferings  inflicted  by  the  fracture  were  very 
great,  and  the  union  slow  or  imperfect,  sometimes  failing  alto- 
gether, and  in  some  instances  inducing  so  much  constitutional 
irritation  as  finally  to  wear  out  the  powers  of  life.  The  prog- 
nosis, therefore,  seems  to  depend  more  upon  the  sound  condi- 
tion of  the  bone  at  the  time  of  fracture,  than  upon  the  degree 
of  mere  fragility. 

With  regard  to  treatment,  it  would  hardly  seem  probable 
that  what  may  be  regarded  as  a  mere  peculiarity,  such  as  ob- 
tains in  simple  fragility,  could  be  influenced  in  any  important 
degree  by  medicines  or  regimen.  Still,  I  can  conceive,  in  cases 
where  the  peculiarity  shows  itself  in  early  life,  that,  by  a  robust 
regimen,  and  careful  attention  to  all  the  details  of  hygiene, 
something  may  be  done  to  strengthen  slender  bones  as  well  as 
to  improve  a  slender  constitution.  In  those  cases  where  some 
inflammatory  action  has  given  rise  to  the  pains  called  rheu- 
matic, of  which  some  of  these  patients  complain  for  a  long 
period  before  the  first  fracture,  I  am  in  hopes  the  iodide  of 
potassium  may  prove  of  benefit ;  though  my  own  experience 
is  limited  to  the  case  mentioned  above,  and  in  that  the  result 
was  not  very  definite.  Finally,  I  fear  there  are  a  number  of 
cases  where  the  disease  is  general,  where  it  is  severe,  and  par- 
ticularly where  it  has  been  long  continued,  in  which  nothing 
can  be  accomplished  but  the  palliation  of  suffering. 


CHAPTEE  IX. 

TUBERCULAR   DISEASE   OF   BONE. 

THAT  true  tubercle  may  exist  in  bone,  I  believe  is  denied 
by  few  pathologists  ;  that  it  is  a  common  affection  of  bone,  is 
denied  by  many  of  the  most  eminent.  In  the  earlier  days  of 
the  revival  of  pathological  anatomy,  before  the  microscope  had 
revealed  its  immense  multitude  of  facts,  leading  us  to  recon- 
sider and  to  change  all  our  generalizations  on  the  nature  of 


86  DISEASES  OF  BONE. 

morbid  products,  pathologists  easily  found  tubercle  in  bone, 
and  gave  it  a  prominent  position  in  bone  pathology.  Nelaton 
took  the  lead  in  this  department  of  study,  and  his  chapters  on 
tubercle  in  bone  were  among  the  earliest,  and  have  ever  since 
been  recognized  as  among  the  best  of  the  publications  on  this 
subject.  He  accepts  and  describes  every  form  of  tubercle  from 
the  minute  gray  granulation  up  to  the  most  ^extensive  infiltra- 
tion of  crude  yellow  tubercle,  and  has  no  hesitation  in  bring- 
ing them  all  under  the  tubercular  category.  Later  writers, 
among  whom  is  Mr.  Barwell,  whose  careful  and  conscientious 
studies  entitle  his  opinions  to  great  weight,  have  been  disposed 
to  limit  very  much  the  use  of  the  term  tubercle  to  those  in- 
stances in  which  the  normal  history  of  tubercle  can  be  dis- 
tinctly made  out  in  all  its  stages,  and  to  exclude  from  the  list 
a  large  number  of  those  aifections  of  bone  in  which  a  plastic  or 
degenerating  lymph  assumes  the  form,  and  sometimes  rather 
closely  imitates  the  behavior,  of  true  tubercle.  In  fact,  when 
we  reflect  how  close  this  resemblance  is  between  tubercle  and 
degenerating  lymph  in  the  soft  parts  of  the  body,  where  the 
difficult  problems  of  structure  are  so  much  more  easily  unrav- 
elled than  they  can  be  in  the  hard  and  unmanageable  tissue 
of  the  bones,  we  can  easily  find  reason  for  being  particularly 
cautious  in  pronouncing  a  judgment  on  changes  which  we  can- 
not always  satisfactorily  appreciate,  a  judgment  which  there- 
fore we  are  apt  to  found  upon  imperfect  analogies  rather  than 
upon  careful  observations.  It  is  acknowledged  by  all  that  there 
is  here  a  debatable  land,  in  which  it  is  impossible  to  decide  on 
each  individual  instance  as  belonging  either  to  one  category  or 
the  other,  and  it  is  therefore  eminently  wise  not  by  any  violent 
generalization  to  throw  all  cases  under  either  head,  reserving 
opinions  as  to  the  tuberculous  or  non-tuberculous  nature  of  the 
various  deposits,  until  our  knowledge  shall  be  more  extensive, 
or  at  least  more  accurate. 

"With  these  reservations  we  may  say  that  tubercle  in  bone 
presents  itself  under  the  two  forms  usually  described,  of  gray 
granulation  and  of  crude  yellow  tubercle.  The  first  is  com- 
monly regarded  as  the  elementary  form  of  the  disease,  or  at 
least  the  form  most  characteristic  and  unequivocal,  and  there- 
fore, in  settling  the  question  of  tubercle  in  bone,  it  has  been 


TUBERCULAR  DISEASE   OF  BOXE.  87 

sought  for  with  particular  anxiety.  It  is  in  this  search  that 
the  hardness  of  the  bone-substance  interposes  such  great  diffi- 
culties, and  it  is  only  by  the  most  tedious  and  careful  dissection 
that  we  can  arrive  at  any  clear  view  of  the  pathological  condi- 
tions we  are  studying.  Nelaton,  however,  persevering  in  his 
investigations,  claims  to  have  several  times  succeeded  in  de- 
monstrating the  presence  of  the  gray  granulation.  He  says,  in 
describing  one  of  his  dissections  :  "  In  the  centre  of  the  spongy 
tissue  which  occupies  the  base  of  the  great  trochanter  was 
found  a  mass,  of  six  or  seven  lines  in  extent  in  all  directions, 
formed  by  the  aggregation  of  small  pearly  granulations,  of  a 
half  a  line  in  diameter,  and  of  an  opaline-white  color.  Many 
of  these  granulations,  and  particularly  those  Mrhich  were  placed 
near  the  periphery,  were  surrounded  by  a  little  osseous  shell, 
so  thin  and  transparent  that  at  first  sight  it  could  not  be  recog- 
nized ;  in  fact,  its  presence  could  only  be  demonstrated  by  the 
resistance  it  offered  to  any  attempt  to  pierce  it  with  the  point 
of  a  needle.  Some  of  these  granulations  presented,  in  their 
centre,  a  yellow  opaque  point,  evidently  the  indication  of  com- 
mencing transformation."  This  seems  a  distinct  observation 
of  the  gray  granulation,  and  there  are  several  others  on  record. 
The  crude  form  of  tubercle,  or  that  in  which  larger  masses  of 
the  opaque  yellow  material  are  found  variously  disseminated 
through  the  bone,  is  not  only  more  easily  recognizable,  but  is 
much  the  more  common  form  of  the  deposit  in  the  bone-tissue. 
Both  these  forms  of  tubercle  are  usually  found  in  masses  more 
or  less  isolated ;  often  so  distinctly  separated  from  the  surround- 
ing tissues  that  some  authors  have  described  them  as  encysted. 
Both  forms  are  recognized  in  the  soft  parts,  and  particularly  in 
the  lungs,  as  sometimes  assuming  the  character  of  infiltrations, 
and  undoubtedly  the  same  is  true  in  bone ;  but  it  must  be  ac- 
knowledged that,  for  the  gray,  transparent  form,  the  demon- 
stration in  bone  must  be  difficult  and  uncertain.  Nelaton,  with 
his  usual  careful  minuteness,  describes  this  infiltration,  and 
gives  a  case  most  particularly  and  thoroughly  studied  out,  in 
which  this  infiltration  existed  at  a  number  of  points  in  the 
sacrum  and  pubis.  The  case  seems  a  clear  one,  but  the  want 
of  microscopic  examinations  must  always  cause  it  to  be  received 
with  some  doubt  as  to  its  real  nature. 


88  DISEASES  OF  BONE. 

The  crude  yellow  tubercle  is  not  uncommonly  infiltrated 
through  the  spongy  substance  of  the  bone.  The  normal  tissue 
does  not  seem  to  be  displaced  by  the  deposit ;  simply  its  inter- 
stices are  occupied  by  it,  and  its  cavities  filled  up  by  it.  Some- 
times the  deposit  is  firm  and  solid,  sometimes  softer  and  cheesy 
in  its  consistence,  and  sometimes  it  is  not  easy  to  pronounce 
whether  we  have  under  view  an  infiltration  of  soft  tubercle,  or 
of  inspissated  lymph.  In  its  microscopic  characters,  the  tuber- 
cle of  bone  has  no  different  features  from  those  of  tubercle 
elsewhere,  and,  in  its  behavior  after  it  is  deposited  in  the  tis- 
sues, it  obeys  the  same  laws  and  goes  through  the  same  trans- 
formations as  in  the  lungs  or  in  the  lymphatic  glands.  Clini- 
cally, these  changes  have  some  peculiarities  impressed  upon 
them  by  the  peculiarities  of  the  tissue  in  which  they  are  devel- 
oped, but,  in  all  essential  particulars,  tubercle  in  bone  presents 
the  same  history  as  tubercle  in  the  soft  parts.  The  first  change 
noticed  is  that  by  which  the  gray  tubercle  changes  to  the  yel- 
low. This  change  commences  in  the  central  parts  of  the  tu- 
bercle, and  gradually  proceeds  until  the  whole  is  transformed. 
While  this  process  is  going  on,  we  usually  have  an  increase  in 
number  and  size  of  the  deposits,  so  that,  when  the  change  is 
completed,  we  have  large  crude  tubercles  replacing  what  were 
at  first  small  and  scattered  gray  granulations.  That  this 
change  does  occur,  most  of  the  best  authorities  agree ;  but,  that 
it  is  the  invariable  law  of  progress,  is  more  than  doubtful. 
That  some  gray  granulations,  by  aggregation  and  the  yellow 
change,  become  crude  yellow  tubercle,  may  be  considered  as 
certain  ;  but  it  is  equally  certain  that  many,  and  perhaps  most, 
of  the  crude  tubercles  we  encounter,  have  never  had  any  pre- 
vious stage  of  gray  granulation.  Once  having  reached,  how- 
ever, the  stage  of  crude  tubercle,  the  changes  are  more  distinct 
and  more  constant.  The  tubercle  itself  tends  usually  toward 
softening  (Fig.  10).  This  change  also  commences  in  the  centre, 
and  spreads  to  the  circumference.  While  it  is  going  on,  in- 
flammatory action  begins  to  be  developed  in  the  surround- 
ing soft  parts,  the  products  of  which,  mingling  with  the  soft- 
ening tubercle,  favor  its  disintegration  ;  while,  being  retained, 
they  add  to  the  local  irritation.  Soon,  a  process  of  ulceration 
begins,  and  the  cancellous  tissue  slowly  breaks  down,  forming 


TUBERCULAR  DISEASE   OF  BONE. 


irregular  cavities,  which  at  first  contain,  mingled  together, 
the  substance  of  the  softened  tubercle  and  the  purulent 
results  of  the  surrounding  inflammation.  The  rate  at  which 
the  changes  go  on  is  very  vari- 
ous. In  the  circumscribed  tu- 
bercles it  is  said  to  be  more  slug- 
gish than  in  the  infiltrated  form, 
and  again,  the  harder  deposits 
change  more  slowly  than  those 
originally  of  a  softer  consistence. 
In  all  cases,  a  wider  and  wider 
area  is  involved,  and  the  disease 
finally  makes  its  way  to  the  outer 
compact  shell,  which,  either  by  a 
process  of  necrosis,  or  by  a  con- 
tinuation of  the  process  of  ulcer- 
ation,  is  finally  perforated,  and 
the  matter  comes  in  contact  with 
the  soft  parts  surrounding  the 
diseased  region  of  bone.  These 
have  been  already  involved  more 
or  less  in  the  inflammatory  ac- 
tions which,  for  so  long  a  time, 
have  been  going  on  in  the  bone, 
and  they  are  ready  to  contribute  their  share  to  the  mixed,  semi- 
fluid mass  which  is  struggling  slowly  toward  the  surface  ;  and 
thus  we  have  formed  the  tubercular  abscess,  which  finally  opens 
on  the  integument,  and  discharges  a  fluid  composed  of  softened 
tubercle,  mingled  with  the  pus  derived  from  the  inflamed  tis- 
sues which  have  been  traversed,  and  also  the  detritus  of  these 
tissues  as  they  have  yielded  to  ulceration  and  molecular  disin- 
tegration. From  this  point  the  changes  vary  in  different  cases. 
Sometimes  this  seems  to  be  the  termination  of  the  tubercular 
action,  and  reparative  dispositions  begin  to  show  themselves  as 
soon  as  the  evacuation  of  the  morbid  products  is  completed. 
Healthy  granulation  begins,  the  cavities  in  the  bone  and  the 
soft  parts  are  gradually  filled  up,  and  a  perfect  cicatrization 
terminates  the  disease.  This  favorable  behavior  is,  however, 
the  rare  exception,  and,  though  ultimately  we  may  hope,  in  per- 


FIG.  10.— {From  Billroth.) 


90  DISEASES  OF  BONE. 

haps  a  large  number  of  cases,  that  a  cure  will  take  place,  it  is 
not  commonly  realized  without  a  period  of  protracted  local 
disease,  which  gives  to  the  tubercular  morbid  processes  their 
peculiar  character  of  obstinacy  and  of  danger.  These  traits 
they  well  deserve,  and  are  exemplified  in  two  ways :  First,  we 
may  have  in  the  tissues,  immediately  surrounding  the  original 
focus  of  disease,  a  new  deposit  of  tubercular  matter.  This  is 
now  usually  of  the  crude  yellow  variety,  and  of  the  softer  form. 
It  is  more  commonly  infiltrated  in  the  surrounding  tissues, 
bringing  larger  and  larger  districts  under  its  baneful  influence, 
and  going  through  the  same  destructive  processes  above  de- 
scribed, the  whole  series  of  changes  being  repeated  indefinite- 
ly, until  the  local  ravages  and  the  constitutional  cachexia  to- 
gether bring  either  limb  or  life  into  a  hopeless  condition. 
Secondly,  even  if  true  tubercular  deposits  can  no  longer  be 
found  to  take  place,  we  constantly  have  the  ulcerative  actions 
slowly  going  on,  forming  new  excavations,  reaching  into  new 
regions,  keeping  up  foul  and  profuse  discharges,  and,  in  short, 
presenting  all  the  well-known  and  much-dreaded  features  of 
tubercular  caries,  so  hopeless  in  treatment,  and  so  fatal  to  the 
joint  upon  which  it  is  slowly  making  its  destructive  invasion. 
Through  all  their  course  these  changes  are  slow  and  deliberate, 
characterized  by  acute  inflammation  only  as  an  occasional  ac- 
cident, and  accompanied  by  a  condition  of  the  general  system 
of  which  the  local  behavior  is  merely  the  expression,  and  which 
in  its  turn  is  constantly  deteriorating  from  the  irritation  re- 
flected upon  it  from  the  local  disease. 

The  suppuration  which  accompanies  this  process  presents 
often  some  peculiar  features.  Sometimes  the  amount  of  pus 
formed  is  very  small,  never  collecting  into  abscesses,  but,  re- 
maining infiltrated  among  the  degenerating  tissues,  seems  to 
take  no  further  active  part  in  the  process.  Thus  we  have  not 
unfrequently  extensive  tuberculous  destruction  of  the  bodies 
of  the  vertebrae,  and  yet  no  abscess  may  ever  make  its  appear- 
ance. It  would  seem  as  if  the  absorbents  were  able  to  dispose 
of  all  the  dying  particles  of  tissue,  as  well  as  all  the  pus  for- 
mations, so  rapidly  that  no  accumulation  could  take  place,  and 
it  is  well  known  that  these  cases  often  go  through  their  whole 
course,  and  arrive  finally  at  a  complete  cure,  without  the  for- 


TUBERCULAR  DISEASE  OF  BONE.  91 

mation  (certainly  without  the  appearance)  of  any  abscess  what- 
ever. But,  though  extensive  tubercular  disease  may  thus  oc- 
casionally exist  without  the  formation  of  distinct  abscess,  yet 
the  general  fact  is  that,  some  time  during  the  course  of  the  dis- 
ease, abscesses  do  form,  and  it  is  their  course  and  behavior 
which  give  their  peculiar  character  to  all  the  later  stages  of  the 
affection.  Sometimes  these  abscesses  slowly  reach  a  certain 
size,  and  then  seem  to  remain  stationary,  and  even  to  retro- 
grade. Such  are  occasionally  seen  on  the  front  of  the  dorsal 
vertebrae,  where  caries  is  arrested  and  a  cure  beginning.  Some- 
times forming  slowly,  they  grow  out  from  the  diseased  point, 
and  receiving  from  the  tissues  around  them  very  firm  walls, 
they  gradually  extend  in  various  directions,  and,  with  curious, 
fantastic  shapes,  insinuate  themselves  between  and  among  the 
muscles  and  the  bones  and  the  organs,  until  they  reach  into 
regions  perhaps  far  distant  from  their  point  of  origin,  "  and 
hang  like  huge  leeches,"  as  Nelaton  expresses  it,  "  on  the  sides 
of  the  vertebral  column."  He  gives  a  drawing  of  a  specimen 
in  which  these  bags  have  been  dissected  out  from  the  surround- 
ing tissues  and  left  hanging  from  their  points  of  attachment, 
and  their  appearance  as  thus  seen  certainly  justifies  his  simile. 
But  again,  without  appropriating  to  itself  any  such  distinct 
sac,  the  matter  may  gradually  push  its  way,  without  inflamma- 
tion, without  pain,  often  without  any  symptom  marking  its 
travels,  until  it  comes  to  the  surface  at  a^point  far  distant  from 
its  source.  This  is  most  familiarly  illustrated  in  the  psoas  ab- 
scess, accompanying  disease  of  the  bodies  of  the  dorsal  verte- 
brae ;  and  there  are  on  record  numerous  examples  where  the 
pus  has  wandered  to  the  most  wonderful  distances,  and  showed 
itself  in  the  most  extraordinary  situations.  The  ordinary 
course  of  psoas  abscess  is  very  slow  and  very  painless,  and 
often  it  happens  that  the  matter  announces  its  presence  by  a 
fluctuating  tumor  below  Poupart's  ligament,  while  its  course 
along  the  sheath  of  the  muscle  has  not  been  attended  with  suf- 
ficient inflammatory  action  to  give  rise  to  any  pain  or  tender- 
ness that  might  serve  as  a  warning  of  the  mischief  that  was  in 
progress.  In  these  cases  there  seems  to  be  a  mere  burrowing 
of  the  matter  along  the  areolar  interstices,  almost  without  lim- 
iting inflammatory  deposit,  and  therefore  without  the  distinct, 


92  DISEASES  OF  BOXE. 

firm,  and  well-developed  cyst  which  in  other  cases  encloses 
the  pus,  and  very  much  restrains  its  distant  wanderings.  A 
somewhat  similar  history  may  be  given  of  the  abscesses  which 
form  in  connection  with  tubercular  caries  of  the  joints.  Some- 
times they  form  with  ranch  evidence  of  inflammatory  activity, 
break  early,  and  discharge  good  healthy  pus,  and  soon  put  on 
a  reparative  aspect,  which  may  result  in  their  prompt  healing. 
Often,  however  (and  this  is  particularly  the  case  with  the  hip- 
joint),  they  form  slowly  and  travel  quietly  to  a  considerable 
distance  along  the  intermuscular  spaces,  and  then  bulge  out, 
forming  a  painless,  cold,  fluctuating  tumor,  whose  only  vital 
activity  during  months,  and  even  years,  may  be  displayed  in  a 
gradual  and  often  extremely  slow  increase  in  size.  This  con- 
cealed suppuration,  escaping  our  notice  during  the  earlier  part 
of  the  disease,  sometimes  adds  suddenly  to  the  gravity,  both 
of  our  prognosis  and  of  our  diagnosis,  and  the  possibility  of  its 
latent  existence  should  always  be  recognized  and  carefully 
watched. 

After  opening,  these  abscesses  usually  continue  to  behave 
as  their  previous  demeanor  would  lead  us  to  expect.  The  cav- 
ities show  but  little  elasticity  or  tendency  to  contract,  and  it 
is  only  after  a  long  time  that  the  abscess  contracts  into  a 
proper  fistula,  and,  even  when  this  has  occurred,  we  are  never 
quite  sure  that  some  deeper  parts  of  the  original  cavity  may 
not  remain  uncontracted,  and  may  yet  be  burrowing  in  some  new 
direction,  to  surprise  us  with  a  new  opening  in  some  distant 
spot.  The  fistulse  thus  formed  discharge  a  matter  which  varies 
in  its  quality  according  to  the  condition  of  the  diseased  bone 
on  which  they  depend.  It  is  very  apt  to  present  the  appear- 
ances characteristic  of  caries  in  its  ordinary  forms.  It  is  thin, 
sometimes  curdy,  often  acrid,  excoriating  to  the  surface  over 
which  it  flows,  and  particularly,  if  the  tubercular  caries  be  in 
active  progress,  it  is  fetid.  The  further  clinical  history  of  these 
abscesses  depends  on  the  course  of  the  disease  of  which  they 
are  symptomatic.  If  this  be  healing,  the  abscesses  will  also 
gradually  heal,  leaving  deep-seamed  and  purple-colored  scars, 
usually  adherent  to  the  bones  over  which  they  have  been  situ- 
ated, apt  to  reulcerate  from  trifling  causes,  and  only  after  many 
months  becoming  sound  and  white,  and  free  from  tenderness. 


TUBERCULAR  DISEASE   OF  BONE.  93 

The  tendency  of  these  scars  to  contract  in  every  direction  was 
strikingly  shown  in  the  case  of  a  young  girl,  who  recovered 
from  what  seemed  to  be  a  case  of  strumous  disease,  probably 
tuberculous,  of  the  hip-joint,  during  the  course  of  which,  many 
abscesses  formed,  leaving  many  sinuses  running  from  the  dis- 
eased joint,  and  opening  at  various  points  on  the  surface. 
After  all  the  sores  healed,  and  her  health  became  reestablished, 
she  grew  fat.  The  scars  of  the  healed  sinuses  had  contracted 
down  so  firmly  as  to  make  deep  fossae  at  the  point  where  each 
of  them  presented  at  the  surface,  and  the  wall  of  fat  round 
each  of  them  gave  them  the  appearance  of  a  very  deep  umbili- 
cus, at  the  bottom  of  which  was  the  scar.  These,  scattered,  to 
the  number  of  six  or  seven,  over  the  buttock  and  hip,  gave  it 
a  most  extraordinary  appearance.  If,  on  the  other  hand,  the 
disease  of  bone,  on  which  the  abscess  primarily  depends,  be 
progressive  or  even  stationary,  the  abscesses  remain,  sometimes 
the  source  of  a  good  deal  of  irritation  and  annoyance,  and 
sometimes  so  quiescent  that  the  patient  has  no  care  for  them 
except  the  daily  dressing  they  require.  As  a  general  rule, 
their  further  history  and  course  are  intimately  associated  with 
the  primary  bone-disease,  though  occasionally  it  will  happen 
that,  as  said  above,  they  will  show  a  disposition  to  accumulate 
the  pus  in  some  of  their  irregular  cavities,  which  pus,  thus  pre- 
vented from  a  ready  outflow,  sometimes  burrows  silently  and 
extensively  into  regions  where  we  do  not  expect  to  find  it. 

The  disease  thus  described  is  most  frequently  found  to 
affect  the  cancellous  rather  than  the  hard  portion  of  the  bones, 
such  as  the  vertebral  bodies,  the  carpus,  the  tarsus,  and  the 
articular  extremities  of  the  long  bones.  Mr.  Paget  makes  the 
important  observation  that,  "  when  it  affects  bones  that  are 
arranged  in  a  group  or  series,  it  is  usually  found  in  many  of 
them  at  once.  Thus  several  vertebrae,  or  several  carpal  or  tar- 
sal  bones,  are  commonly  at  the  same  time  tuberculous ;  yet  not 
often  so  equally  but  that  one  of  them  appears  first  and  chiefly 
diseased  ;  while,  in  those  gradually  more  distant  from  it  on 
either  side,  the  tuberculous  deposits  are  gradually  less  abun- 
dant. In  like  manner,  the  parts  of  bones  that  act  together  in  a 
joint  are,  usually,  at  the  same  time  tuberculous." 

The  treatment  of  tuberculous  disease  of  the  bones  is,  as  far 


94  DISEASES  OF  BONE. 

as  its  constitutional  character  is  concerned,  no  different  from 
the  treatment  of  tuberculous  disease  elsewhere,  and  it  seems 
scarcely  worth  while  to  repeat  here  what  has  been  so  well  said 
by  systematic  writers  on  tuberculosis.  The  local  management, 
however,  presents  many  features  of  individual  importance,  and 
demands  our  most  careful  study.  So  much  of  this  local  treat- 
ment depends  more  on  the  eifects  than  on  the  nature  of  the 
affection,  and  so  much  of  it  is  included  in  the  history  of  the 
treatment  of  caries,  in  its  various  forms,  that  I  reserve  all  that 
I  have  to  say  on  the  subject  till  we  have  discussed  the  latter 
disease,  to  which  nearly  all  the  cases  of  tuberculosis  are  so 
naturally  related. 


CHAPTER  X. 

CAKIES. 

CAEIES  is  a  condition  of  bone  in  which  suppuration  and 
ulceration  are  combined,  but  in  a  proportion  so  varying  that  it 
has  been  found  somewhat  difficult  to  give  a  concise  definition 
of  the  disease.  Different  authors,  looking  at  the  prominence 
of  one  or  the  other  of  these  processes,  have  described  it  either 
as  a  suppuration  or  an  ulceration,  as  one  or  other  action  seemed 
to  them  most  important,  and  hence,  perhaps,  there  is  no  disease 
in  which  there  is  more  apparent  discrepancy  of  view  and  of 
statement  than  in  this.  "Without  attempting,  therefore,  to  de- 
fine caries,  I  will  content  myself  with  describing  it  as  a  disease 
of  the  cancellous  structure  of  bone,  characterized  by  a  chronic 
or  subacute  inflammation,  terminating  in  suppuration,  which 
is  partly  infiltrated,  and  partly  collected  into  abscesses,  the 
cavities  of  which  abscesses,  after  they  have  discharged  their 
contents,  have  a  tendency  to  ulceration,  whereby  sometimes 
extensive  destruction  of  bone-tissue  results.  With  this  there 
are  usually  to  be  marked  some  abortive  attempts  at  reparation, 
such  as  large,  flabby  granulations  protruding  into  the  ulcerated 
cavities,  and  irregular  and  ineffectual  depositions  of  new  bone 
in  and  about  the  diseased  parts.  It  is  essentially  chronic  in 


CARIES.  95 

its  character,  showing  very  little  disposition  toward  healing, 
and  it  is  generally  associated  with  some  constitutional  cachexia, 
or  local  unfavorable  condition,  on  which  its  existence,  seems 
to  depend 

Commencing  our  studies  with  this  general  description,  we 
shall  further  find  that  caries  sometimes  presents  itself  as  a  dis- 
order arising  from  some  slight  exciting  cause,  and  running  its 
course  without  any  evident  connection  with  or  dependence 
upon  any  other  disease  or  injury ;  while  sometimes  it  is  mani- 
festly dependent  on  some  disease  or  injury  of  which  it  seems  to 
be  the  consequence  and  effect.  This  seems  to  me  to  justify  a 
distinction  into  primary  or  idiopathic  and  secondary  or  symp- 
tomatic caries,  a  distinction  which  I  think  is  found  in  Nature, 
and  will  be  useful  in  practice. 

Taking,  now,  a  case  of  primary  or  idiopathic  caries  as  a  type 
of  the  disease,  we  shall  find  that  in  a  young  person,  who  has 
probably  already  presented  some  of  the  evidences  of  a  strumous 
disposition,  a  slight  swelling,  with  some  pain  and  tenderness, 
presents  itself  in,  we  will  say,  a  wrist-  or  an  ankle-joint.  This 
is  at  first  attributed  to  some  sprain  or  other  injury,  and  then 
to  rheumatism.  The  inconvenience  caused  by  the  affection  at 
this  stage  may  be  very  slight,  and  the  patient  may  continue  to 
use  the  limb  without  distress ;  but  soon  stiffness  after  exercise, 
and  more  or  less  pain  on  motion,  begin  to  show  themselves, 
and  the  joint  gradually  grows  more  disabled  as  the  disease 
advances.  The  affection  becomes  more  and  more  markedly  in- 
flammatory, involving  the  surrounding  parts  in  its  increase, 
but  evidently  centring  its  effects  on  the  bones  of  the  tarsus  or 
carpus,  rather  than  on  the  ankle-  or  wrist-joint.  Gradually, 
and  generally  very  slowly,  the  motion  of  the  parts  gets  to  be  so 
painful  that  the  limb  becomes  entirely  disabled,  and  soinetimes 
constant  pain  is  experienced  independent  of  any  movement, 
pain  which  is  worse  at  night,  and  aggravated  by  damp  and 
changeable  weather.  Soon  the  inflammatory  signs  begin  to 
concentrate  themselves  at  one  point,  and  a  fluctuation  and  a 
pointing  announce  the  formation  of  abscess.  These  abscesses 
are  not  usually  large,  and,  when  they  break,  discharge  a  mod- 
erate amount  of  thin,  flaky  pus.  Little  or  no  disposition  is 
shown  toward  any  healing  action  in  the  abscess,  the  discharge 


96 


DISEASES  OF  BONE. 


from  which  continues,  generally  consisting  of  a  thin,  acrid 
irritating,  and  bad-smelling  pus  in  moderate  quantities.  No 
relief  of  the  symptoms,  but  rather  an  exaggeration  of  suffering, 
occurs  after  the  abscess  has  broken,  and,  if  not  before,  now  cer- 
tainly, constitutional  sympathy 
begins  to  declare  itself.  Fever 
of  a  hectic  character  develops 
itself,  emaciation  is  marked,  and 
the  patient  becomes  a  confirmed 
invalid.  The  progress  of  the 
constitutional  symptoms  varies 
very  much  in  different  individ- 
uals, the  general  deterioration 
progressing  very  rapidly  in 
some,  and  in  others  so  slowly  as 
scarcely  to  be  marked,  even 
when  local  destruction  has  made 
extensive  progress.  Of  course, 
the  size  and  importance  of  the 
joint,  and  the  extent  of  the  dis- 
ease will  have  much  to  do  with 
the  gravity  of  the  general  affec- 
tion. New  abscesses  now  form 
at  various  points  round  the  dis- 
eased centre,  deformity  increases, 
and  sometimes,  as  in  the  knee, 
displacement  of  the  joint -sur- 
faces takes  place,  owing  to  the 
loss  of  tone  in  the  ligaments, 
which  may  proceed  so  far  as  to 
simulate  a  real  luxation.  These 

abscesses,  particularly  those  accompanying  caries  of  the  ver- 
tebrae, are  often  of  the  cold  variety,  and  extend  sometimes  to 
a  great  distance  from  the  original  seat  of  the  disease.  The 
psoas  abscess  is  an  example  of  this  pathological  fact,  and  we 
often  find  the  matter  travelling  into  very  distant  and  unex- 
pected regions  before  it  approaches  the  surface.  Fig.  11, 
copied  from  Erichsen's  work  on  Surgery,  shows  the  extensive 
wanderings  of  an  abscess  originally  developed  on  the  anterior 


FIG.  11.— (From  Erichsen.) 


CARIES.  97 

surface  of  the  bodies  of  the  lumbar  vertebrae.  The  soft  parts, 
in  these  confirmed  conditions  of  caries,  are  extensively  impli- 
cated, being  thickened  and  consolidated  by  the  inflammatory 
exudations,  and  traversed  in  various  directions  by  sinuses, 
which  lead,  often  indirectly,  from  the  diseased  bone  to  the  sur- 
face. This  condition,  once  established,  may  last  for  an  indefi- 
nite period,  and  may  have  one  of  two  terminations :  It  may 
either  settle  down  into  an  inactive  and  unchanging  condition, 
lasting  for  months,  and  even  years,  without  any  manifest  prog- 
ress ;  or  it  may  go  on  through  a  process  of  local  disorganiza- 
tion and  general  depreciation,  which  brings  the  patient  to  the 
point  where  both  life  and  limb  are  imperilled,  and  where  the 
interference  of  art  is  imperatively  demanded.  If,  on  the  other 
hand,  a  favorable  change  is  to  take  place,  we  have  again  one 
of  two  results  to  hope  for :  First,  an  improvement  in  all  the 
conditions  of  the  part,  and  a  gradual  restoration  to  health,  with 
such  an  impairment  of  the  joints  affected  as  shall  not  entirely 
interfere  with  the  usefulness  of  the  limb ;  or,  secondly,  in  the 
more  advanced  cases,  we  have  to  hope  that,  if  the  destructive 
actions  be  arrested,  a  gradual  consolidation  shall  take  place, 
such  as  will  permit  a  return  of  soundness  to  the  diseased  tis- 
sues, though  at  the  expense  of  an  anchylosis  either  partial  or 
complete — an  anchylosis,  the  ill-effects  of  which  mechanical 
ingenuity  can  often  very  much  neutralize,  and  which  in  some 
instances  surgical  art  can  measurably  improve. 

Symptomatic  or  secondary  caries  has,  of  course,  no  such 
distinct  history  of  its  own,  but  is  developed  in  connection 
with  some  injury  or  disease  of  the  surrounding  soft  parts,  upon 
which  it  depends.  Long-continued  destructive  inflammations 
of  joints  very  often  produce  this  carious  condition  of  the  bones 
which  compose  them.  Thus,  we  often  find,  in  white  swelling 
of  the  knee,  that  the  disease  has  involved  the  head  of  the  tibia, 
and  sometimes  the  condyles  of  the  femur  so  far  that  the  bone- 
disease  has  assumed  the  prominence  both  in  prognosis  and  in 
the  indications  of  treatment.  This  is  sometimes  particularly 
well  marked  in  the  conditions  of  joints  which  have  been  de- 
stroyed by  inflammation  following  penetrating  wounds.  In 
these  cases  it  is  well  known  that  the  cartilage  rapidly  disap- 
pears under  the  influence  of  the  inflammatory  actions  set  up  by 
7 


98  DISEASES  OF  BOXE. 

the  wound,  and  the  articular  lamella  is  early  exposed.  From 
this  the  inflammation  gains  ready  access  to  the  cancellous  tis- 
sue underneath,  and  we  have  infiltrated  suppuration  and  caries 
as  the  common  consequence. 

The  symptoms  indicating  secondary  caries  are  usually  so 
mingled  with  those  of  the  original  disease  that  it  is  not  easy 
to  separate  them.  The  extension  of  the  joint  swelling  so  as 
manifestly  to  embrace  the  joint  ends  of  the  bones ;  the  tender- 
ness and  pain  in  the  heads  of  the  bones ;  abscesses  breaking  at 
a  distance  from  the  joint  and  over  enlargements  such  as  above 
described,  and  the  detection  of  carious  bone  by  the  probe — these 
are  the  most  striking  and  unequivocal  symptoms  of  this  form 
of  caries ;  but  it  may  be  stated  that  the  long  continuance  and 
destructive  behavior  of  joint-affections  generally  may  lead  to 
the  suspicion  that  caries  of  the  articular  extremities  of  the 
bones  has  taken  place. 

From  this  sketch  of  the  clinical  features  of  the  two  varie- 
ties of  caries  we  may  now  proceed  to  a  study  of  its  pathologi- 
cal anatomy.  Bsyond  a  doubt,  the  first  morbid  conditions 
which  would  be  found  in  a  bone  which  was  falling  into  caries 
would  be  those  of  inflammatory  excitement.  Increased  vascu- 
larity  throughout  the  cancellous  tissue  is,  however,  a  patho- 
logical fact  sometimes  difficult  to  verify.  The  violence  caused 
by  the  saw  leaves  a  surface  which  always  seems  too  red  to  be 
healthy,  and  in  young  people  the  circulation  in  the  heads  of 
the  long  bones  is  so  active  that  in  the  most  healthy  specimens 
we  find  what  seem  to  be  the  evidences  of  great  and  irregular 
congestion.  Much  care,  therefore,  must  be  exercised  in  decid- 
ing upon  the  existence  of  diseased  states  of  the  circulation  in 
these  cases,  and  conclusions  should  not  be  too  positive.  The 
increased  action  is  soon  accompanied  by  exudation.  This  exu- 
dation— at  first  a  reddish  serum — is  infiltrated  through  the 
bone,  and  tends  very  soon  to  be  converted  into  pus — a  pus, 
however,  which  does  not  assume  a  very  perfect  form,  and 
•which  at  first  seems  disposed  to  remain  disseminated  rather 
than  to  collect  in  the  form  of  abscesses.  This  imperfect  sup- 
puration has  no  doubt  often  been  mistaken  for  true  tubercular 
infiltration  of  bone,  which  is  certainly  a  rare  condition,  but  it 
should  be  remembered  that  the  lines  between  true  tubercle  and 


CARIES. 


99 


imperfect  suppuration  are  not  very  cleanly  drawn,  and  that, 
though  it  is  extremely  rare  to  find  in  bone  a  deposit  which 
answers  the  description  and  obeys  the  laws  of  tubercle,  yet  we 
do  often  find,  in  this  imperfectly-de- 
veloped suppuration,  in  scrofulous 
subjects,  something  which,  histologi- 
cally  and  pathologically,  very  closely 
assimilates  to  it.  As  the  disease  pro- 
gresses, it  takes  on  more  and  more  dis- 
tinctly the  characters  of  disseminated 
suppuration,  and  collections  of  mat- 
ter, gradually  accumulating,  begin  to 
show  themselves,  at  various  points, 
forming  abscesses.  Some  increase  in 
activity  accompanies  the  formation 
of  these  abscesses,  and  they  seek  the 
surface  with  some  signs  of  acute  in- 
flammation. They  point  and  break, 
or  are  opened  by  the  surgeon,  and 
discharge  a  small  quantity  of  mat- 
ter, which,  according  to  the  activity 
of  the  inflammation,  has  more  or 
less  of  the  character  of  healthy  pus. 
Frequently  it  presents  the  thin  curdy 
or  flaky  character  which  is  consid- 
ered characteristic  of  struma.  These 
abscesses  show  no  tendency  to  heal, 
and  yet  a  reparative  disposition  is 
evinced  by  large  granulations,  soft, 
flabby,  which  spring  up  and  usually 
fill  to  a  great  extent  the  suppurating 
cavities.  Instead  of  being  truly  re- 
parative, however,  the  presence  of  these  granulations  is  not  in- 
compatible with  an  ulcerative  action  by  which  the  cavities  are 
being  slowly  enlarged,  and  the  cancellous  tissue  more  and  more 
extensively  broken  down.  This  destruction  of  the  bone-tissue 
is  a  complicated  process,  and  seems  to  be  made  up  of  two  kinds 
of  action,  one  where  the  bone-substance  undergoes  a  change  in 
which  its  earthy  element  is  absorbed,  and  the  other  a  true  pro- 


FIG.  12.— (From  Billroth.) 


100  DISEASES   OF   BONE. 

csss  of  ulcerative  absorption  whereby  the  altered  bone  is  re- 
moved (Fie1.  12).  The  changes  which  go  on  in  bone  during 
this  process  are  extremely  interesting,  and  have  been  fully 
investigated  by  many  recent  observers.  Mr.  Barwell,  in  his 
work  on  "  Diseases  of  the  Joints,"  gives  a  very  full  account 
of  his  observations  on  this  subject,  which  seem  to  have  been 
made  with  great  care  and  thoroughness.  He  considers  the 
first  change  to  be  an  enlargement  of  the  lacunae  and  their 
canaliculi.  The  lacunae  gradually  lose  the  elongated  shape 
and  approach  to  circular  or  broad  oval.  The  canaliculi  are 
larger  and  more  numerous,  and  seem  to  open  into  the  lacunae 
by  broad  mouths.  Where  the  canaliculi  intersect  each  other, 
there  seem  to  be  new  spaces  formed,  which  assume  the  charac- 
ters of  new  lacunae.  Thus  there  is  a  positive  increase  in  the 
number  as  well  as  the  size  both  of  the  lacunae  and  canaliculi. 
During  this  change,  the  bone -substance  itself  undergoes  a 
transformation,  which  commences  nearest  to  the  llaversian 
canal  or  cancellus  and  spreads  outward.  The  bony  sub- 
stance becomes  granular;  that  is  to  say,  it  looks  as  if  it 
were  composed  of  dark  and  light  dots  placed  close  together. 
As  this  change  spreads  from  the  Haversian  canal  or  cancellus 
outward,  the  margins  of  the  cavity  lose  their  distinctness  of 
outline  and  become  very  irregular ;  in  parts  the  edge  is  gone, 
the  cavity  is  therefore  on  that  side  increased  ;  in  other  parts 
the  spotted  bone-tissue  appears  to  mingle,  or  to  be  continuous 
with  some  granular  contents  of  the  cavity.  It  is  quite  evident 
that,  in  these  places,  the  bone-tissue  is  softened  ;  one  can  trace 
the  gradual  completion  of  the  process,  from  some  point  which 
is  only  slightly  spotted,  to  the  part  next  the  cavity,  which  is 
a  mere  pultaceous  granular  mass,  in  which  many  of  the  dots 
have  the  appearance  of  nuclei. 

"  Another  change  in  the  cell  forms  part  of  this  softening 
process,  viz. :  that  as  the  dotted  or  granular  condition  reaches 
a  certain  stage,  so  do  the  canaliculi  disappear  ;  therefore,  of 
course,  from  that  side  first,  which  is  turned  toward  the  cavity 
(Haversian  or  cancellar),  they  vanish  by  simple  shortening,  by 
recession  from  the  entirely  softened  bone,  until  they  are  re- 
duced to  mere  little  rudimentary  projections  on  the  surface  of 
the  cell.  At  this  time  the  cell  itself  is  visible,  as  a  granulated 


CARIES. 


101 


dark  bag,  more  or  less  transparent,  and  very  highly  refracting, 
which  projects  from  the  wall  of  the  scarcely-resistant  bone,  and 
is  of  large  size  ;  it  bulges  out  and  seems  swollen,  projects  more 
and  more,  and  at  last  breaks  away  from  its  attachment,  and 
lies  among  the  softened  debris  in  the  cavity,  still  retaining  its 
dark  color.  In  breaking  away,  however,  it  often  leaves  behind 
those  of  its  canaliculi  which  were  turned  away  from  the  cavity, 
and  which  may  often  be  seen  on  the  edge,  but  which  soon  dis- 
appear as  softening  goes  on,  spreading  outward.  Frequently 
several  smaller  cells  come  out  of  the  lacuna,  instead  of  one 
large  one.  In  this  way  a  lamina  between  two  cancellous  cavi- 
ties very  soon  disappears,  from  softening  on  both  sides  :  in  this 
way,  also,  circlet  after  circlet  of  cells  around  an  Haversian  ca- 
nal caves  into  the  cavity,  and  thus  the  system  melts  away  and 
leaves  around  the  vessel  only  a  soft  granular  and  cellular 


FIG.  13.— (From  Billroth.) 

mass."     Fig.  13  shows  the  worm-eaten  appearance  of  carious 
bone  under  the  microscope. 

By  these  processes,  the  bone-substance  becomes  gradually 


102  DISEASES   OF  BONE. 

disintegrated,  so  that,  before  actual  ulceration  has  taken  place, 
it  is  so  softened  that  the  scalpel  or  even  the  probe  can  be  read- 
ily pushed  through  it.  In  some  points  the  bone-elements  seem 
to  disappear  entirely ;  in  most,  however,  some  of  the  original 
framework  remains  so  as  to  maintain  the  shape  of  the  part. 
Not  nnfrequently,  from  this  softened  condition  of  the  joint- 
ends,  great  deformity  results  from  unequal  yielding  to  press- 
ure— a  circumstance  which,  the  vertebrae  excepted,  I  have 
more  frequently  noticed  in  the  knee  than  in  any  other  joint, 
and  one  which,  if  a  favorable  change  takes  place  in  the  origi- 
nal disease,  leaves  behind  a  distortion  which  is  permanent  and 
irremediable.  As  the  process  of  ulceration  goes  on,  some  parts 
of  the  bone-substance  are  apt  to  die,  giving  rise  to  small  se- 
questra, generally  upon  the  ulcerated  surfaces,  which  thus  at- 
tract less  attention,  because  easily  cast  out  with  the  discharges. 
These  sequestra  which  accompany  caries,  however,  are  occa- 
sionally of  considerable  size,  and  assume  great  importance 
when,  as  is  sometimes  the  case,  they  involve  the  articular 
lamella,  and  fall  into  the  joint-cavity ;  thus  forming  a  com- 
plication which  renders  the  destruction  of  the  joint  almost  a 
certainty.  Where  much  of  this  necrotic  action  accompanies 
caries,  the  disease  is  spoken  of  as  caries  necrotica. 

While  these  destructive  actions  are  going  on,  reparative  dis- 
positions show  themselves  unequivocally,  though  ineffectually, 
in  the  diseased  parts.  We  have  already  noticed  the  luxuriant 
granulations  which  fill  the  cavities  of  the  abscesses ;  the  bone- 
tissue  shows  the  same  tendency.  Mr.  Barweil  thinks  he  has 
ascertained  that,  in  the  early  period  of  the  disease,  the  bony 
lamellae  become  thickened  and  indurated,  as  one  stage  of  the 
inflammatory  process.  This  must  be  a  pathological  fact  ex- 
tremely difficult  to  verify,  but,  be  it  as  it  may,  it  is  certain  that 
later  in  the  disease  new  bony  deposit  is  seen  around  the  cen- 
tral points  of  carious  bone,  as  almost  a  universal  fact.  Some- 
times this  is  only  noticed  to  the  extent  of  some  slight  surface 
incrustations  round  the  diseased  spots,  but  commonly  there 
are  considerable  thickening  and  consolidation  through  the  sub- 
stance, and  often  a  very  great  amount  of  stalagmitic  deposit 
on  the  whole  of  the  neighboring  surfaces,  and  sometimes  ex- 
tending to  the  nearest  bones,  which  may  themselves  be  entirely 


CARIES. 


103 


free  from  other  signs  of  disease  (Fig.  14).  In  the  caries,  so 
common,  of  the  bodies  of  the  vertebrae,  this  deposit  is  often 
seen  to  be  very  extensive,  forming  bridges  of  bone  between 


FIG.  14.— (From  Bfflroth.) 


FIG.  15.— (From  New  York  Hospi- 
tal Museum.) 


neighboring  vertebrae,  as  if  to  strengthen  the  column,  while 
the  disease  is  still  progressing ;  and  as  favorable  changes  he- 
gin  to  take  place  in  the  carious  parts,  fresh  and  stronger  devel- 
opments of  new  bone  are  observed,  which  finally  fuse  together 
in  one  solid  anchylosis  the  vertebrae  whose  bodies  have  been 
more  or  less  completely  destroyed  by  the  ulceration  (Fig.  15). 

When  a  cure  is  about  to  take  place  in  ordinary  cases  of 
caries,  the  ulcerative  action  ceases;  the  granulation-substance 
assumes  a  healthier  and  firmer  character,  and  gradually  or- 
ganizes itself  into  tissue.  The  suppuration  ceases,  and  the  in- 
flammatory congestion  diminishes.  New  bone-deposit,  formerly 
confined  to  the  outskirts  of  the  disease,  now  is  deposited  so  as 
in  part  to  restore  the  deficiencies  which  have  occurred.  Some- 
times this  action  is  a  prominent  one,  the  granulations  spring- 
ing from  opposite  bones  coalescing  and  ossifying ;  and  in  this 
way  we  have  true  anchylosis  as  one  of  the  methods  of  cure  in 


104  DISEASES   OF   BONE. 

bones  which  have  been  long  and  extensively  carious  (Fig.  1C). 
A  modification  of  this  conservative  action  is  sometimes  ob- 
served in  carious  bones  which  have  formed  part  of  an  artieula- 


Fia.  16. — (From  New  York  Hospital  Museum.) 

tion ;  that  the  opposed  surfaces,  from  which,  perhaps,  cartilage 
has  long  been  removed,  as  healthy  action  is  resumed,  become  hard 
and  smooth,  so  as  to  allow  of  a  certain  amount  and  freedom  of 
motion,  which  tolerably  preserve  the  usefulness  of  the  mem- 
ber. This  induration  of  the  surfaces  is  sometimes  so  complete 
as  to  assume  the  appearance  of  ivory  or  porcelain,  and  hence 
it  is  often  spoken  of  as  the  porcellanous  or  ivory-like  change. 
Finally,  in  cases  where  the  ravages  of  the  disease  have  not 
been  so  extensive  as  to  disorganize  the  neighboring  joint,  we 
may  have  a  recovery  so  perfect  as  to  leave  no  impairment  of 
function,  and  no  traces  other  than  the  cicatrices  both  in  the 
bone  and  in  the  surrounding  soft  parts,  which  must  necessarily 
follow  the  ulcerative  actions  which  have  been  going  on. 

Caries,  in  all  its  forms,  is  emphatically  a  disease  of  the 
cancellous  tissue ;  indeed,  it  would  be  somewhat  difficult  to 
comprehend  how  the  compact  substance  could  take  on  the 
actions  of  primary  caries.  A  secondary  invasion  of  the  com- 
pact substance  in  the  neighborhood  of  active  caries,  whereby 
it  is  gradually  changed  in  its  structure  by  a  process  of  osteopo- 
rosis, and  then  invaded  by  the  ulcerative  actions  proper  to 
caries,  is  not  at  all  uncommon  ;  but  any  such  action  developed 
as  a  primary  affection  must  be  regarded  as  exceedingly  rare. 
The  bones  most  commonly  affected  by  primary  caries  are  the 
the  bodies  of  the  vertebrae,  the  tarsal  and  carpal  bones.  The 
•joint-ends  of  the  tibia  and  humerus  are,  among  the  long  bones, 
the  most  frequently  attacked,  but  no  bone  is  entirely  exempt. 
Fig.  17,  from  the  New  York  Hospital  Cabinet,  shows  the  ex- 
tent to  which  carious  destruction  will  sometimes  proceed. 
The  specimen  here  represented  is  from  "  a  mulatto  seaman, 


CARIES. 


105 


who  suffered  from  excruciating  pain  in  the  left  ear,  with  deaf- 
ness and  swelling,  for  several  months,  at  the  end  of  which  time 
he  died  comatose.  Patient  had  nodes  and  other  symptoms  of 
syphilis.  On  examination,  the  disease  was  found  to  have  de- 
stroyed almost  the  whole  of  the  petrous  portion  of  the  tempo- 


Fio.  17. — (From  New  York  Hospital  Museum.) 

ral  bone.  The  dura  mater  had  been  either  absorbed  or  decom- 
posed, and  an  immense  collection  of  pus  extended  along  the 
whole  of  the  base  of  the  brain.  After  maceration,  the  remain- 
der of  the  temporal  and  a  large  part  of  the  left  half  of  the 
occipital  bone,  extending  into  the  foramen  magnum,  the  left 
portion  of  the  body  of  the  sphenoid,  and  a  part  of  the  arch  of 
the  atlas,  were  found  to  have  crumbled  to  pieces,  thus  leaving 
a  hole  admitting  the  closed  fist." 

The  disease  is  almost  entirely  confined  to  persons  below 
the  age  of  puberty ;  though  a  few  cases  of  caries  occur  in 
highly-scrofulous  .young  adults.  The  caries  of  the  vertebrae, 
independent  of  injury,  is  almost  unknown  after  puberty,  while 
the  disease  in  the  tarsus  and  carpus  is  occasionally  seen  in  the 


106  DISEASES   OF  BOXE. 

adult.  In  general,  it  may  be  stated  that  primary  caries  is  an 
affection  of  childhood  and  early  maturity,  while,  strange  to 
say,  secondary  caries  is  of  comparatively  rare  occurrence  in 
childhood,  but  frequent  in  the  injuries  of  bone  and  inflamma- 
tions of  joints  which  occur  in  adult  life.  It  would  seem  as  if 
the  abundant  vitality  of  the  child  protected  him  against  secon- 
dary caries,  as  a  consequence  of  injury ;  but  that  that  very 
abundant  vitality,  if  tainted  with  constitutional  vice,  tends  to 
crop  out  in  primary  caries  and  its  allied  diseases  in  early  life  : 
whilej  if  the  individual  survive  these  early  perils,  the  consti- 
tutional taint  seems  often  to  disappear  in  a  vigorous  maturity, 
and  with  it  disappear  the  peculiar  tendencies  to  disease  which 
characterized  and  imperilled  his  childhood.  It  need  hardly  be 
added  that  no  bone  and  no  age  are  entirely  protected  against 
secondary  caries. 

The  prognosis  of  caries  is  always  bad;  that  is  to  say, 
wherever  the  disease  has  fully  developed  itself,  serious  conse- 
quences are  sure  to  follow.  These  consequences  may  be  lim- 
ited to  some  local  destruction  of  bone -tissue,  which  may  be 
repaired  to  such  a  degree  that  the  form  and  usefulness  of  the 
bone  may  not  be  lost ;  or  they  may  be  so  severe  that  destruc- 
tion of  joints  and  peril  to  life  may  become  imminent — peril 
from  which  amputation  or  exsection  alone  can  extricate  the 
sufferer;  or,  finally,  in  not  a  few  cases,  either  in  spite  of  the 
resources  of  surgical  art,  or  because  we  cannot  bring  them  to 
bear,  death  will  be  the  result.  In  primary  caries,  every  thing 
seems  to  me  to  depend  on  the  condition  of  the  constitution. 
If  this  be  deeply  tainted  with  scrofula,  the  case  is  almost  hope- 
less from  the  beginning.  If,  on  the  contrary,  the  scrofulous 
manifestations  are  not  marked ;  if  the  system  be  in  a  tolerably 
vigorous  condition  ;  if  the  remedies  and  the  regimen  employed 
have  the  effect  to  invigorate  and  improve  the  general  health  ; 
then  we  have  a  good  ground  for  hope  that  the  local  disorder 
will  prove  tractable,  and  particularly  if  our  remedies  are 
brought  to  bear  early  in  the  case.  Indeed,  I  think  this  an  ele- 
ment in  prognosis  second  only  to  the  constitutional  state ;  viz., 
the  stages  at  which  the  disease  falls  under  surgical  care.  If 
remedies,  and  particularly  regimen,  can  be  wisely  employed  in 
the  earlier  and  forming  stages  of  carious  disease,  I  do  not 


CARIES.  107 

hesitate  to  class  it  among  the  manageable  affections.  If  they 
are  not  afforded  till  the  destructive  features  of  the  disease  are 
developed,  we  can  do  little  to  avert  its  consequences.  Youth 
does  not  seem  to  modify  the  prognosis  so  favorably  as  in  other 
diseases,  as  the  strumous  taint  of  young  subjects  seems  to  be 
more  distinct  and  more  disastrous  than  in  those  somewhat 
older ;  but,  nevertheless,  I  think  it  may  be  safely  said  that, 
other  things  being  apparently  equal,  young  children  do  better 
with  carious  disease  than  those  in  the  neighborhood  of  puberty. 
One  other  element  in  prognosis  should  not  be  overlooked,  viz., 
social  condition.  Those  who  from  wealth  and  intelligence  can 
command,  and  will  use  with  steadiness  and  perseverance,  all 
the  best  resources  of  art,  have  a  vastly  better  chance  in  this  dis- 
ease of  securing  a  favorable  result,  than  can  be  looked  for  in  those 
whose  circumstances  will  not  permit  them,  and  whose  intelli- 
gence will  not  guide  them,  in  the  wise  use  of  means  whose  care- 
ful application  may  have  to  be  continued  through  long  and 
weary  months,  and  perhaps  years,  of  doubtful  and  anxious  care. 
That  the  treatment  of  caries  is,  as  a  general  thing,  ex- 
tremely unsatisfactory,  I  suppose  no  surgeon  of  any  experience 
would  be  disposed  to  deny.  And  yet,  most  good  surgeons  do 
not  hesitate  to  acknowledge  the  efficacy  of  certain  remedies, 
and  certain  modes  of  management,  in  particular  stages  and  in 
particular  conditions  of  the  disease.  The  study  of  treatment 
may  here  be  advantageously  divided  into  two  stages  or  periods; 
one  which  represents  the  commencing  or  inflammatory  stage, 
and  the  other  which  has  to  do  with  the  consequences  and 
effects  of  the  inflammation.  It  is  manifest  that  these  periods 
cannot  be  defined  with  accuracy,  and  that  they  must  vary  in 
different  individuals,  and  yet  in  most  cases  there  can  be  dis- 
tinguished a  period  where  the  inflammation  is  going  through 
its  stages  of  congestion  and  effusion  of  serum,  of  lymph,  and 
of  pus,  when  the  inflammation  itself  is  the  main  feature  of  the 
disease,  and  requires  to  be  the  main  object  of  attack  in  the 
treatment.  Again,  when  the  results  of  this  inflammation  have 
developed  themselves  into  abscess,  ulceration,  necrosis,  and  ex- 
tended disorganization,  it  is  no  longer  so  much  the  inflamma- 
tion, as  its  results,  that  we  have  to  do  with,  and  these  conse- 
quences now  have  become  the  main  features  of  the  case,  while 


108  DISEASES   OF  BONE. 

the  inflammatory  action  itself  may  have  ceased  to  be  an  object 
of  special  consideration.    In  the  first  stage,  then,  we  have  to  deal 
with  an  inflammation  which  is  essentially  subacute,  and  will 
hardly  bear  active  depletion.     Nevertheless,  a  few  leeches  over 
the  affected  part,  perhaps  repeated  at  intervals,  will  certainly 
control  tbe  tenderness  and  pain,  and  seem  to  have  a  good  effect 
in  preparing  the  way  for  other  remedies.     I  have  sometimes 
employed  this  treatment  in  the  earliest  stages  of  hip-disease, 
depending  on  osteitis,  with  a  good  effect  in  quelling  the  noc- 
turnal attacks  of  pain,  with  which  the  first  stages  of  this  affec- 
tion are  sometimes  accompanied.     Two  or  three  leeches  behind 
the  trochanter  in  these  cases  have  seemed  to  me  to  do  good, 
particularly  if  repeated  at  intervals  of  ten  days  or  two  weeks. 
At  the  same  time  free  local  depletion  is  not  allowable.     The 
local  actions  are  too  sluggish,  and  too  much  dependent  on  con- 
stitutional  causes,  to   be  favorably  modified  by   considerable 
losses  of  blood ;  and  it  should  always  be  remembered  that  the 
vital  powers  of  the  part  are  to  be  taxed  heavily  for  many 
weeks  and  months,  and  it  would  be  very  poor  preparation  for 
such  effort,  to  weaken  the  part  by  too  much  cr  too  frequent 
local  bleeding.     Blisters  may  also  be  of  service  in  relieving 
pain,  and  it  is  reasonable  to  believe  that  a  positive  advantage 
may  be  derived  from  counter-irritation,  particularly  if  perios- 
teal  surfaces  are  the  seat  of  the  inflammation.     "We  are  cau- 
tioned by  most  writers  against  applying  blisters  too  near  the 
seat  of  an  inflammation,  a  caution  which  probably  in  acute 
synovial  affections  of  the  joints  is  a  wise  one.     In  cases  of 
osteitis,  which  we  fear  will  prove  to  be  caries,  however,  I  have 
never  hesitated  to  apply  my  blister  immediately  over  the  affect- 
ed part,  and  have  always  felt  that  its  action  was  useful  in  pro- 
portion to  the  precision  with  which  it  could  be  brought  to  bear 
on  the  threatened  locality,  and  I  have  never  realized  any  injury 
which  seemed  to  me  attributable  to  transmission  of  the  surface 
irritation  to  the  parts  beneath.     In  the  use  of  blisters  in  these, 
and  indeed  in  all  cases,  I  have  the  conviction  that  it  is  their 
primary  effect  which  is  the  valuable  one,  and  that  they  are  very 
poor  and  very  un  com  fort  able  derivatives.     If  any  such  perma- 
nent drain  is  desired,  it  is  much  better  attained  by  an  issue  or 
seton,  and  I  never  now  keep  my  blisters  sore. 


CARIES.  109 

The  more  powerful  derivatives,  the  issue,  the  seton,  etc., 
have  in  former  times  been  very  generally  regarded  with  high 
favor  in  the  treatment  of  caries ;  but  whether  their  importance 
has  not  been  exaggerated,  admits,  I  think,  of  a  question.  Mr. 
Brodie  speaks  unhesitatingly ;  he  says :  "  I  much  doubt  whether 
setons  and  issues  are  ever  useful,  except  in  some  cases  in  which 
the  disease  has  its  seat  in  the  hip-joint."  Mr.  Barwell  gives 
them  credit  for  doing  some  good  in  the  earlier  or  inflammatory 
stage,  but  denies  them  all  value  in  the  second  or  destructive 
condition  of  the  bone  ;  while  he  acknowledges  that  their  ap- 
plication, and  particularly  in  the  form  of  the  actual  cautery, 
has  a  marked  effect  in  arresting  the  pain  of  the  disease — an 
arrest  which  he  insists  is  always  very  temporary.  Both  from 
reasoning  and  experience,  I  have  been  disposed  to  accord  a 
higher  value  to  these  remedies  than  is  given  them  by  these  dis- 
tinguished writers,  but  every  thing,  I  think,  depends  on  the 
character  of  the  individual  case  to  which  they  are  applied.  In 
those  sluggish,  painless,  slowly-progressing  disorganizations  of 
the  bone  which  are  found  in  connection  with  what  we  call 
white  swelling  of  the  joints,  where  every  local  action  seems  the 
expression  and  result  of  a  constitutional  cachexia,  and  when 
the  ordinary  demeanor  of  inflammation  is  entirely  masked  by 
that  cachsxia,  I  acknowledge  that  little  or  no  benefit  is  to  be 
derived  from  this  class  of  remedies.  But  in  all  those,  perhaps 
more  numerous  cases,  where  the  inflammatory  processes  show 
some  of  their  normal  activity,  and  where  it  is  rather  the  appre- 
hension that  the  vital  actions  will  be  modified  by  strumous 
sluggishness,  than  that  they  actually  indicate  the  presence  of 
that  unfortunate  taint,  and  where  great  sensitiveness  on  motion 
or  uss  shows  that  more  acute  action  could  be  easily  lighted  up, 
and  when  particularly  the  case  is  complicated  with,  and,  as  it 
were,  interrupted  by,  attacks  of  acute  inflammations  from  no 
very  obvious  causes,  then  I  conceive  that  we  have  in  perma- 
nent derivation  a  very  important  means  of  controlling  and 
often  of  curing  the  disease.  In  these  cases  the  seton  or  issue 
(and  I  greatly  prefer  the  issue),  placed  a  little  distance  above  the 
affected  bone,  and  so  arranged  as  not  to  interfere  with  the  ap- 
paratus which  is  to  be  applied,  nor  with  the  motion  which  by- 
and-by  will  have  to  bo  made,  and  kept  running  with  issue-peas 


HO  DISEASES  OF   BONE. 

until  the  actions  begin  to  indicate  clearly  that  the  tendencies 
are  toward  cure,  and  then  allowed  to  diminish  in  amount 
of  suppuration,  and  gradually  to  dry  up,  is,  as  I  believe,  a 
very  positive  agent  in  promoting  the  cure.  In  this  respect, 
the  actual  cautery  holds  a  high  position.  Its  primary  action 
is  so  peculiar  and  energetic  that  it  controls  with  great  cer- 
tainty the  symptoms  of  the  disease  for  a  time,  and  its  result- 
ant issue  is  the  best  that  can  be  made.  In  the  most  acute 
cases,  when  much  pain  is  an  early  and  prominent  symptom,  I 
consider  it  peculiarly  valuable. 

The  use  of  mercury  in  osteitis  tending  to  caries  has  also 
been  the  subject  of  much  difference  of  opinion  among  good 
surgeons.  My  own  experience  is  unequivocal,  and  has  im- 
pressed me  strongly  with  its  value  in  appropriate  cases.  And 
these  will  embrace  the  early  stage  of  a  large  proportion  of  the 
whole  ;  all,  indeed,  excepting  those  of  very  feeble  constitution 
and  irritable  fibre.  Two  ways  of  using  mercury  are  commonly 
employed  with  entirely  different  indications,  one  as  a  purga- 
tive and  the  other  as  an  alterative.  The  purgative  action  is 
supposed  to  clear  the  intestines  of  such  vitiated  secretions  as 
oppose  their  proper  action  upon  the  alimentary  mass,  and  in 
this  way  indirectly  improve  the  character  of  the  nutritive  ac- 
tions, while  the  alterative  effect,  obtained  by  the  continuous 
administration  of  small  doses,  is  supposed  to  show  itself  not 
only  in  an  improvement  of  these  nutritive  actions,  but  also  and 
principally  in  a  direct  effect  upon  the  course  of  the  inflamma- 
tory disease  which  it  is  supposed  to  affect  favorably.  Both 
these  modes  of  using  mercury  are  useful  in  this  disease.  In 
the  forming  stage  of  such  cases  as  occur  in  patients  of  tolerable 
vigor,  and  with  inflammatory  symptoms  of  some  activity,  mer- 
curial purgatives  occasionally  administered  have  the  happiest 
effect  in  improving  the  general  condition  of  the  system,  and 
often  in  directly  relieving  some  of  the  most  distressing  of  the 
local  symptoms.  Mr.  Barwell  very  happily  illustrates  this  ef- 
fect by  the  well-known  influence  of  mercurial  cathartics  in  cer- 
tain cases  of  strumous  ophthalmia,  where  such  surprising  relief 
is  often  found  to  accompany  their  proper  employment. 

The  alterative  method  also  has  its  value  in  cas^.s  where  the 
progress  of  inflammation  seems  steadily  onward,  increasing  its 


CARIES.  Ill 

area  and  accompanied  by  distressing  pain  and  starlings  at  night, 
with  fever,  more  or  less  distinctly  developed,  at  irregular  inter- 
vals. In  these  cases  the  careful  use  of  calomel,  combined  with 
opium  in  small  doses,  has  seemed  to  me  in  many  instances  to  have 
had  the  happiest  effect,  both  on  the  sufferings  of  the  patient  and 
on  the  progress  of  the  disease.  In  more  chronic,  less  distinctly 
inflammatory  cases,  I  have  much  confidence  in  the  controlling 
power  of  the  bichloride,  used  in  exceedingly  small  doses,  say 
the  twenty-fourth  or  thirty-second  part  of  a  grain  twice  or 
thrice  a  day,  combined  with  tonics,  and  perseveringly  employed 
for  weeks  or  even  months.  I  need  hardly  say  that  in  all  the 
methods  of  employing  mercury  its  injurious  effects  should  be 
carefully  guarded  against — hypereatharsis  on  the  one  hand, 
and  salivation  on  the  other,  being  likely  to  inflict  more  mis- 
chief than  the  happiest  influence  of  the  drug  can  compensate 
for. 

In  regard  to  the  necessity  for  rest  of  the  diseased  part  dur- 
ing the  earlier  stages  of  caries,  all  authors  are  agreed,  and  their 
judgment  is  in  accordance  with  the  instinctive  feelings  of  the 
patient.  Much,  however,  depends  upon  the  thoroughness  with 
which  absolute  rest  is  not  only  insisted  on,  but  by  appropriate 
arrangements  secured.  In  the  acute  eases,  when  the  disease  is 
in  the  lower  limbs,  the  bed  is  the  only  security  against  injuri- 
ous and  painful  motion  ;  and  even  in  bed  it  is  often  necessary 
to  apply  some  apparatus  to  the  limb  to  secure  it  against  in- 
voluntary and  accidental  movements.  As  almost  all  cases  of 
caries  occur  in  immediate  proximity  to  joints,  the  treatment 
of  the  bone-disease  involves,  in  all  its  stages,  the  proper  man- 
agement of  the  joint,  and  here  the  indication  is  to  keep  the 
joint  immovable  in  order  to  give  rest  to  the  inflamed  bone  in 
its  neighborhood ;  and  much  comfort,  and  I  am  sure  much  ad- 
vantage, is  secured  to  the  patient  by  splints  so  arranged  as  to 
secure  him  against  the  painful  movements  to  which  accident 
or  muscular  spasm  makes  him  continually  liable.  About  these 
points  there  can  be  but  little  diversity  of  opinion  or  practice, 
but  the  more  important  question  presents  itself:  How  long 
shall  absolute  rest  be  maintained,  and  how  soon  and  to  what 
extent  may  use  be  allowed  ?  I  believe  there  is  no  more  im- 
portant practical  point  in  the  history  of  these  diseases,  and  I 


112  DISEASES  OF  BONE. 

am  sure  there  is  none  requiring  more  careful  and  enlightened 
judgment. 

The  importance  of  this  point  arises  out  of  the  fact  that  dis- 
use of  a  limb  is  certain  to  be  followed  by  atrophy,  and  atrophy 
means  degeneration.  Now,  where  this  degeneration  of  all  the 
tissues  of  a  limb  has  been  going  on  through  months  of  disuse, 
it  seems  to  me  to  be  certain  that  the  reparative  powers  of  the 
part  must  be  depreciated  in  a  proportional  degree,  and  I  have 
long  been  of  opinion  that  many  cases  of  chronic  surgical  dis- 
ease are  prolonged  indefinitely,  and  sometimes  brought  to  an 
unfavorable  issue,  by  this  loss  of  reparative  vitality,  from  too 
long-continued  disuse.  It  is  confessedly  a  difficult  point  to 
decide  when  passive  motion  and  when  active  use  should  be 
allowed  in  these  cases,  and  I  do  not  feel  competent  to  lay  down 
distinct  rules  by  which  practice  should  here  be  guided.  The 
general  principles  of  action  ara  that,  as  soon  as  active  inflam- 
mation has  sufficiently  subsided,  the  use  of  the  limb  will  pro- 
mote the  vital  activities  which  have  been  held  in  abeyance  by 
disuse  ;  and  that,  therefore,  we  should  endeavor  to  seize  the 
moment  when  inflammation  will  not  be  aggravated,  and  when, 
therefore,  nutritive  activity  will  be  increased  by  appropriate 
exercise  of  the  limb.  In  judging  of  this,  we  must  be  guided 
principally  by  two  symptoms,  viz.,  the  heat  and  the  tenderness 
of  the  part.  If  heat  have  steadily  and  permanently  subsided, 
until  the  ordinary  condition  of  the  diseased  part  is  one  of  natu- 
ral temperature,  as  appreciated  by  the  hand  or  by  the  thermom- 
eter, and  if  at  the  same  time  tenderness  have  so  far  diminished 
that  moderate  pressure  is  no  longer  painful — always  provided 
that  the  other  morbid  signs  have  also  been  undergoing  a  favor- 
able change — we  may  suppose  that  the  time  for  considering  the 
question  of  passive  motion  has  arrived.  And  perhaps  there  is 
no  bettsr  way  of  ascertaining  the  fact  than  by  cautiously  mak- 
ing the  experiment.  When,  therefore,  circumstances  seem  to 
indicate  that  the  proper  time  has  come,  careful  and  very  slight 
movements  of  the  joint  should  be  made  by  the  surgeon's  own 
hands,  for  this  is  a  thing  that  should  never  ba  committed  to 
the  patient  or  his  attendants,  repeated  daily  or  at  such  inter- 
vals as  may  seem  best.  Undoubtedly  all  local  symptoms  will 
be  increased  for  the  time  by  such  a  procedure,  which  in  its 


CARIES.  113 

performance  will  give  the  patient  much  pain.  This  need  not 
necessarily  forbid  its  repetition,  and  by  no  means  indicates  that 
it  is  not  judicious,  and  it  is  only  by  its  ulterior  effect  that  the 
wisdom  of  the  manipulation  can  be  vindicated.  One  practical 
precept,  for  the  clinical  enforcement  of  which  we  were  all  in- 
debted to  Dr.  Alexander  H.  Stevens,  then  Surgeon  of  the  !N"ew 
York  Hospital  as  well  as  Professor  of  Surgery  in  the  College 
of  Physicians  and  Surgeons,  seems  to  me  a  safe  and  useful 
guide  in  this  matter,  viz. :  if  the  pain  and  tenderness  produced 
by  passive  motion  last  more  than  twenty-four  "hours,  we  have 
done  too  much  ;  if,  on  the  other  hand,  how  much  soever  pain 
we  may  give  in  the  manipulation,  its  effects  have  entirely 
passed  away  by  the  same  hour  of  the  next  day,  we  may  be 
encouraged  to  proceed.  Without  claiming  this  rule  to  be  a 
positive  guide,  I  can  say  that  I  have  found  it  a  very  useful 
assistant  in  my  own  cases,  and  one  which  has  very  rarely  seri- 
ously misled  me.  Another  and  an  important  point  is  still  to 
be  decided,  as  to  when  the  use  of  the  limb  may  be  advanta- 
geously permitted.  This  question  will  no  doubt  generally  de- 
cide itself,  as  the  results  of  passive  motion  are  developed,  but 
still  cases  present  themselves  where  passive  motion  has  been 
sometimes  employed  without  manifest  injury,  and  yet,  where 
no  improvement  follows,  and  where  the  general  atrophy  of  the 
limb  is  so  decided  as  to  lead  to  the  belief  that  nothing  but  the 
stimulus  of  use  will  bring  about  a  healthier  reparative  condi- 
tion. In  these  cases  careful  but  courageous  use,  perseveringly 
and  judiciously  insisted  upon,  seems  the  only  way  of  solving 
the  problem — a  solution  which  is  sometimes  among  the  happi- 
est and  most  satisfactory  of  surgical  therapeutical  results. 

In  securing  the  complete  rest,  so  necessary  in  the  earlier 
stages  of  caries,  position  is  most  carefully  to  be  attended  to. 
The  limb  will  usually  have  assumed,  if  the  disease  have  been 
long  in  existence,  a  position  to  which  the  patient  has  been  in- 
stinctively led  by  finding  it  most  comfortable.  This  position  is 
usually  one  of  moderate  flexion  of  the  joint  implicated,  if  it  be 
a  large  joint,  as  the  knee  or  elbow,  while  the  wrist  or  ankle 
will  be  kept  nearly  midway  between  flexion  and  extension, 
which  will  bs  for  the  wrist  nearly  a  straight  position,  and  for 
the  ankle  about  a  right  angle  of  the  foot  with  the  leg.  It  often 
8 


114  DISEASES   OF  BONE. 

happens,  however,  that  this  position  has  been  allowed  to  be- 
come a  vicious  one,  and  one  which,  if  maintained  till  a  cure  is 
accomplished,  would  leave  the  limb  in  a  more  or  less  deformed 
and  useless  condition.  These  faulty  positions  may  be  almost 
invariably  rectified  by  gradual  and  very  careful  extension  which 
may  be  applied  by  the  apparatus  used  for  securing  the  rest  of 
the  limb.  Our  instrument-makers  make  a  very  excellent  light 
frame,  well  padded  with  soft  leather,  which,  moving  on  a  hinge 
at  the  situation  of  the  joint,  can  be  flexed  or  extended  by  a 
screw.  This  screw  is  moved  by  a  key,  which  is  retained  by  the 
surgeon  or  the  nurse,  so  that  in  unruly  children  no  letting  up 
of  the  pressure  can  be  accomplished  without  proper  advice. 
By  the  steady  and  gradual  application  of  a  gentle  force,  the 
rectification  of  position  can  usually  be  accomplished  without 
division  of  tendons.  With  some  surgeons  this  division  of  ten- 
dons and  contracted  muscles  is  much  resorted  to,  and  much  ad- 
vantage is  reported  as  being  gained  in  the  treatment,  in  reliev- 
ing both  the  spasmodic  and  the  permanent  contraction  of  the 
muscles.  My  own  experience  does  not  entitle  me  to  pronounce 
on  its  value,  as  I  have  rarely  had  occasion  to  resort  to  it. 

If  the  case  have  been  under  our  care  from  the  onset,  then 
there  is  a  mode  of  securing  rest  to  the  limb,  the  most  complete 
and  comfortable  that  can  be  attained,  which  prevents  any  pos- 
sibility of  a  faulty  position,  and  which  is  attended  with  the 
very  great  advantage  of  relieving  the  pressure  of  the  joint 
surfaces  against  one  another,  produced  by  the  tonic  contraction 
of  the  muscles  surrounding  the  joint.  I  allude  to  what  is  now 
commonly  spoken  of  as  elastic  extension.  Extension  is  applied 
to  the  limbs  by  means  of  the  adhesive  bands,  and  the  weight  and 
pulley,  as  is  now  universal  in  the  treatment  of  fractured  thigh, 
and  this,  in  the  case  of  the  knee  or  hip,  is,  made  while  the 
patient  is  lying  on  the  back,  and  at  other  joints  in  varying 
positions  according  to  the  part  involved.  Somewhere  between 
the  pulley  and  the  limb,  a  band  of  India-rubber  is  introduced 
through  which  all  the  traction  passes,  and  this  by  its  elasticity 
so  equalizes  the  extension  that  it  is  always  in  uniform  action, 
and  can  be  borne  without  the  least  inconvenience.  The 
advantages  of  this  mode  of  managing  the  earliest  stages  of 
joint  aifections  are  incontestable ;  and  in  caries  it  cannot  be 


CARIES.  115 

less  important,  both  to  the  comfort  and  to   the  cure  of  the 
patient. 

When  caries,  as  is  too  often  the  case,  proves  unmanageable 
by  all  the  remedies  employed  to  check  its  progress,  we  have 
often  presented  to  us  a  surgical  problem  which  deals  with  the 
results  of  the  carious  disorganization,  and  in  which  the  main 
question  is,  What  shall  be  done  with  the  hopelessly-diseased 
bone,  and  in  what  way  can  it  best  be  prevented  from  inflicting 
injury  on  the  surrounding  healthy  tissues,  and  on  the  patient's 
general  health  ?  This  problem  embraces  the  destruction  or  the 
removal  of  the  diseased  bone,  and  must,  of  course,  in  its  full 
decision,  depend  upon  all  the  particular  circumstances  of  situa- 
tion, degree,  age,  general  condition,  etc.,  which  give  individual 
character  to  the  case.  Some  general  considerations,  applicable 
to  all  cases,  however,  will  help  us  in  the  solution  of  each  par- 
ticular problem.  The  destruction  of  the  diseased  tissue  may 
be  eifected  either  by  the  stronger  escharotics,  or  by  the  actual 
cautery.  The  difficulty  of  limiting  the  action  of  a  caustic, 
and  the  uncertainty  of  its  effects,  have  been,  I  suppose,  the 
reasons  why  they  have  not  usually  been  employed  for  this  pur- 
pose ;  while  the  completeness  of  the  destruction,  and  the  cer- 
tainty with  which  we  can  calculate  upon  its  extent,  are  good 
reasons  for  preferring  the  hot  iron.  The  most  favorable  cases 
for  the  use  of  this  method  of  treatment  must  be  those  where 
the  disease  is  either  not  extensive,  or  is  mainly  situated  over  a 
surface  which  can  be  easily  reached  by  the  application.  To 
such  cases  the  iron  is  applied  at  a  full  red  heat,  holding  it  on 
the  diseased  part  until  its  full  effect  is  produced.  Of  course,  a 
careful  preparatory  exposure  of  the  bone  will  be  made,  and  the 
soft  parts  drawn  aside,  and  carefully  protected  against  the  heat. 
The  destruction  of  tissue  thus  produced  is  usually  not  so  deep 
as  would  at  first  sight  appear,  but  it  is  perfect,  and  the  whole 
burnt  substance  now  occupies  the  wound  only  as  a  sequestrum, 
which  soon  separates  and  is  cast  off,  leaving  either  a  healthy 
granulating  surface,  or  one  which  indicates  that  the  diseased 
tissue  is  not  all  removed.  If  this  be  found  to  be  the  case,  then 
the  application  must  be  repeated  at  proper  intervals  as  often  as 
may  be  necessary.  The  older  writers  speak  very  highly  of  this 
method  of  attacking  caries,  but  it  seems  to  have  lost  credit 


116  DISEASES   OF  BONE. 

with  the  more  modern  surgeons ;  perhaps,  because  the  various 
operations  for  removal  of  diseased  bone  have  attracted  so  much 
of  their  attention,  and  are,  after  all,  the  only  operations  to  be 
relied  on  when  the  carious  disease  has  involved  the  greater 
part  or  the  whole  of  a  bone,  or  of  several  contiguous  bones. 

The  operation  of  exsection  or  excision  of  bone  is  compara- 
tively a  modern  one — Mr.  White,  of  Manchester,  being  com- 
monly regarded  as  the  first  who,  by^a  defined  and  purposed  pro- 
cedure, undertook  the  removal  of  carious  bone,  he  having  re- 
moved the  head  of  the  humeras  for  caries  in  the  year  1T68. 
Since  his  time,  surgeons  have  been  gradually  growing  to  the  ap- 
preciation of  the  important  step  thus  indicated,  and  no  operation 
has,  during  the  last  fifty  years,  commanded  more  universal  in- 
terest than  that  of  excision  of  carious  bone,  particularly  in 
connection  with  the  diseases  and  injuries  of  joints.  The  prin- 
ciple of  the  operation  is  founded  on  the  fact  that  the  caries  is 
localized  in  its  action,  and  that,  when  the  diseased  parts  are 
removed,  healthy  reparative  processes  may  De  expected  to  begin, 
and  the  success  of  the  operations  founded  upon  this  principle 
may  be  properly  said  to  have  inaugurated  a  new  era  in  the 
treatment  of  diseased  conditions  of  the  joints.  Exsection  has 
now  been  practised  on  almost  every  bone  in  the  body ;  and 
while  the  value  of  the  procedure  varies  much  according  to  the 
locality  affected,  yet  no  doubt  remains  of  the  great  value  and 
importance  of  the  operation  itself. 

The  operation  consists  in  exposing  the  diseased  bone  by 
appropriate  incisions,  and  then,  with  the  saw,  or  the  bone-for- 
ceps, removing  all  that  portion  which  is  implicated  in  the  dis- 
order. As  this  operation  is  so  commonly  performed  for  caries 
as  a  part  of  joint  disorganization,  it  is  usually  performed  in 
such  manner  as  to  expose  and  remove  both  of  the  opposed  joint 
surfaces,  and  it  is  this  operation  which  is  meant  when  we  speak 
of  exsection  or  excision  of  the  joints.  In  operating  thus, 
great  care  is  to  be  taken  not  to  interfere  any  further  than  is 
necessary  with  tendinous  insertions,  in  order  not  to  impair  the 
efficiency  of  the  muscular  actions  of  the  joint,  and  also  not  to 
remove  any  more  of  the  bone  than  disease  makes  necessary. 
It  is  true  that  Nature  has  wonderful  resources  in  repairing  the 
mutilation  of  this  procedure,  and  surgeons  have  not  hesitated 


CARIES.  117 

to  remove  several  inches  of  each,  bone  where  it  has  been  clearly 
necessary,  but  the  rule  of  saving  all  that  may  be  saved  is  none 
the  less  imperative,  and  the  success  of  the  procedure  will,  in  a 
good  degree,  depend  upen  the  amount  of  bone  which  is  taken 
away.  "Where  the  operation  is  successful,  one  of  two  results  is 
realized  :  first,  the  wounded  surfaces  take  on  a  healthy  action, 
and  the  bone  granulates,  and  a  uniting  medium  thus  forms 
which  ultimately  becomes  firm  enough  to  produce  an  anchylo- 
sis between  the  opposing  bones ;  while,  at  the  same  time,  all 
diseased  action  ceases,  and  the  soft  parts  cicatrize  soundly. 
This  is  the  result  most  commonly  aimed  at,  and,  probably, 
always  most  desirable  in  the  lower  extremity.  In  the  upper 
extremity,  however,  a  certain  amount  of  motion  is  hoped  for, 
and  quite  frequently  a  useful  degree  of  it  is  attained.  The 
uniting  medium  does  not  completely  solidif}7,  but  remains  suf- 
ficiently yielding  to  imitate  some  of  the  movements  of  the 
original  joint;  while,  if  the  tendinous  insertions  have  not  been 
too  extensively  disturbed,  the  muscles  resume  their  power,  and 
an  amount  of  voluntary  motion  is  regained  which  is  often  ex- 
tremely valuable  in  the  shoulder,  the  elbow,  and  the.  wrist 
joint.  In  realizing  these  two  different  results,  of  course,  much 
will  depend  upon  the  management  of  the  limb  after  operation. 
If  firm  anchylosis  is  desired,  absolute  rest  will  be  most  care- 
fully maintained  during  all  the  cure ;  while,  if  motion  is  sought 
for,  properly  conducted  passive  motion  will  be  the  principal 
means  of  arriving  at  the  result  desired. 

The  success  of  these  operations  has  been  extremely  satis- 
factory, and,  when  we  consider  that  the  alternative  presented  is 
amputation,  we  can  hardly  accord  too  high  a  position  to  this 
great  conservative  triumph  of  modern  surgery.  Two  modifica- 
tions of  the  operation  of  excision  for  caries  have  lately  been 
presented  to  the  surgical  world,  by  men  of  eminent  repute, 
both  claiming  superiority  over  the  rival  proposal,  as  well  as 
over  the  old  operation.  These  are  brought  forward  respective- 
ly by  M.  Oilier,  of  Lyons,  and  by  M.  Sedillot,  of  Paris ;  both 
are  fortified  by  a  considerable  number  of  cases,  and  both  are 
reasoned  out  with  great  scientific  ability.  M.  Oilier  claims 
that  the  trus  method  of  excision  is  what  he  calls  the  sub-peri- 
osteal  section  ;  that  is,  one  in  which  the  diseased  bone  is  re- 


118  DISEASES  OF  BONE. 

moved,  leaving  behind  its  periosteal  covering.  According  to 
his  views,  which  indeed  are  those  generally  received,  the  peri- 
osteum is  the  great  bone-producer,  very  greatly  superior  in  this 
power  to  any  of  the  surrounding  tissues,  or  even  to  the  bone 
itself.  If,  therefore,  in  any  exsections  of  bone,  we  leave  the 
periosteum  behind,  we  have  the  element  of  reproduction  of 
the  bone  to  help  us  in  the  reparative  processes  which  we  are 
anticipating;  so  that,  if  every  thing  proceeds  favorably,  we 
accomplish,  by  sub -periosteal  resection,  not  merely  the  removal 
of  the  disease,  but  the  regeneration  of  the  bone  removed,  so 
perfectly  and  to  such  an  extent  as  makes  the  result  more  per- 
fect and  more  complete  than  can  in  any  other  way  be  accom- 
plished. M.  Sedillot  contends  that  the  periosteum  cannot  be 
relied  upon  to  do  its  full  regenerative  duty  in  these  cases,  and 
that  the  only  way  to  secure  a  complete  reformation  of  the  bone 
to  be  removed,  is  so  to  proceed  as  to  leave  a  thin  shell  of  bone 
attached  to  the  periosteum,  from  which  shell  he  says  there  will 
be  the  most  perfect  possible  regeneration  of  the  bone  removed. 
His  operation  consists,  therefore,  in  scooping  out  all  the  dis- 
eased bone-tissue,  leaving  behind  a  thin  layer  of  bone,  attached, 
of  course,  to  the  periosteum,  and  forming  thus  a  thin  shell 
which  maintains  the  shape  and  size  of  the  bone  removed,  thus 
preventing,  according  to  M.  Sedillot,  the  deformity  which  ne- 
cessarily follows  the  other  operation,  and  which,  M.  Sedillot 
believes,  will  not  in  any  material  degree  be  prevented  by  M. 
Ollier's  sub-periosteal  method.  Much  has  been  said,  and  many 
cases  have  been  published  in  the  journals,  by  some  of  the  most 
eminent  surgeons  of  Europe,  on  this  subject,  and  the  result 
of  all  the  discussion  seems  to  be  that  neither  operation  is  en- 
titled to  exclusive  preference ;  but  that,  while  the  old  operation 
is  the  only  one  which  can  be  performed  in  perhaps  the  greater 
number  of  cases,  yet  there  are  a  certain  number  in  which  the 
new  operations  will  realize  many  of  the  advantages  claimed  by 
their  enthusiastic  originators.  Active  minds  are  industriously 
employed  on  this  interesting  subject  in  every  country,  and  the 
appreciation  of  the  various  operative  methods  bids  fair  to  be 
soon  practically  settled.  Mr.  Hancock,  in  London,  has  done 
more  than  any  other  man  to  illustrate  and  enforce  M.  Sedillot's 
views,  and  very  numerous  experimenters  in  Europe  and  in  this 


NECROSIS.  119 

country  have  proved  tbe  value  of  M.  Ollier's  important  sug- 
gestions. While,  therefore,  some  features  of  the  operation  of 
exsection  of  bones  may  still  be  considered  as  not  yet  fully  and 
finally  decided  upon,  the  general  value  of  the  operation  and 
its  estimation  as  a  surgical  resource  are  gaining  daily,  and  it 
now  ranks  as  one  of  the  most  valuable  contributions  of  modern 
science  to  conservative  surgery. 


CIIAPTEK  XI. 

NECKOSI8. 

THE  death  of  bone,  so  common  in  its  occurrence,  either  as 
a  primary  and  essential,  or  as  a  secondary  and  accidental  cir- 
cumstance, is  one  of  the  most  extensive  and  interesting  sub- 

'  O 

jects  which  bone  pathology  presents.  For  the  frequency  of 
its  occurrence  two  circumstances,  connected  with  its  vascular 
supply,  present  themselves  in  explanation  :  First,  the  perios- 
teum contains  a  larger  part  of  the  vessels  whose  small  branches 
pass  inward  to  supply  the  superficial  or  sub-periosteal  layers  of 
bone-tissue,  and  upon  the  integrity  of  this  membrane,  and  upon 
its  close  adhesion  to  the  bone,  depends  the  continuance  of  this 
supply  of  blood.  !Now,  it  so  happens  that  the  periosteum  is 
liable  to  injury  or  inflammation,  which  may  either  destroy  it 
in  situ,  or,  what  is  more  common,  may  cause  an  effusion  be- 
tween it  and  the  bone,  which,  separating  it  from  the  bone, 
destroys  the  continuity  of  circulation  between  the  vessels  of 
the  periosteum  and  of  the  adjacent  bone  which  these  vessels 
should  nourish.  In  this  way,  there  is  no  doubt,  many  super- 
ficial necroses  take  place,  and  a  considerable  proportion  of  the 
thin  exfoliations  we  so  often  see  after  slight  injuries  are  thus 
produced. 

But,  in  the  second  place,  there  is,  in  the  expansibility  of 
bone-tissue,  another  and  more  widely  operating  cause  of  necro- 
sis. All  the  circulation  in  the  substance  of  bone  is  through 
vessels  traversing  bony  canals  which  they  entirely  fill,  and 
which  canals,  therefore,  compress  and  support  the  vessels  on  all 
sides.  Under  the  first  stimulus  of  inflammation  in  the  soft 


120  DISEASES  OF  BONE. 

parts,  it  is  well  known  that  the  vessels  are  crowded  with  blood 
so  as  to  be  largely  dilated  in  their  calibre.  This  dilatation 
would  seem  to  be  a  necessary  mechanical  result  of  the  increased 
quantity  of  blood  forced  into  tubes  whose  walls  are  capable  of 
yielding,  and  it  would  also  seem  to  be  a  necessary  vital  action 
whereby  the  yielding  vessel  grows  more  capable  of  transmit- 
ting the  increased  current  of  blood,  which,  without  this  relief, 
would  be  dammed  up  and  stagnate  in  the  capillaries  of  the 
part,  thus  arresting  entirely  the  circulation,  which,  if  life  is  to 
continue,  should  only  be  retarded,  not  stopped  entirely.  Of 
this  yielding  to  dilating  force,  of  course,  the  vessels  of  the  bone 
are  by  their  position  entirely  incapable.  In  bone  inflammation, 
therefore,  the  blood,  attracted  by  the  new  stimulus,  crowds  the 
unyielding  capillaries  so  urgently  that  transmission  of  the  cur- 
rent becomes  slower  and  slower,  the  thinner  parts  of  the  blood 
move  on,  while  the  corpuscles  become  more  and  more  jammed 
and  packed  in  the  channel  now  relatively  too  small  to  receive 
their  increased  number,  until  presently  the  current  is  arrested 
altogether,  and  the  circulation  ceases. 

Thus  it  would  appear  that  one  essential  element  of  acute 
inflammation  of  bone  is  such  a  mechanical  condition  of  the 
affected  part  as  directly  tends  to  the  destruction  of  life — a 
destruction,  the  certainty  of  which  depends  probably  more  on 
the  acuteness  of  the  attack  than  on  its  severity  or  extent. 
That  this  is  so  we  are  instructed  by  observing  that  the  delib- 
erate actions  of  chronic  inflammation,  though  extensive  and 
severe,  are  very  little  liable  to  produce  necrosis,  whatever 
other  disastrous  accidents  they  may  entail,  apparently  because 
the  vascular  movements  are  of  such  a  character  as  to  give  time 
for  the  vessels  and  their  bony  canals  to  accommodate  them- 
selves to  changes  which,  in  the  acute  inflammations,  hurry  on 
the  bone  to  death.  These  considerations  may  also  serve  to 
explain  the  fact  that  the  compact  tissue  of  bone  is  more  liable 
to  necrosis  than  the  cancellous.  In  the  cancellous  tissue  a 
large  part  of  the  circulation  is  distributed  through  the  medulla, 
the  terminal  capillaries  alone  entering  the  bony  channels,  and 
hence  any  increased  hydraulic  pressure  is  received,  in  great 
part,  upon  vessels  which  have  the  space  in  which  to  expand. 
In  the  compact  tissue,  on  the  other  hand,  the  whole  vascular 


NECROSIS.  121 

system  of  the  part  is  contained  within  the  rigid  Haversian 
canals,  and  the  pressure  is  resisted  equally  by  the  capillaries 
and  the  vessels  from  which  they  spring.  Hence,  doubtless, 
the  comparative  frequency  in  the  one  and  the  rarity  in  the 
other  tissue  of  an  accident,  which  has,  in  its  nature,  no  ele- 
ments of  difference  besides  the  mechanical  one  upon  which  we 
are  now  insisting. 

From  the  study  of  these  intrinsic  predisposing  conditions, 
we  may  deduce  the  most  important  exciting  cause  of  necrosis, 
namely,  inflammation ;  or,  in  other  words,  we  may  appreciate 
the  reason  of  the  acknowledged  fact  that  inflammation  is  the 
great  producing  cause  of  necrosis.  All  those  accidents  and 
exposures  which  are  likely  to  induce,  and  all  those  conditions 
of  the  system  which  favor,  the  occurrence  of  inflammation  in 
any  of  the  component  tissues  of  the  bone,  may  be  regarded  as 
the  exciting  and  predisposing  causes  of  necrosis. 

Of  the  predisposing  causes,  we  have  those  that  are  local 
and  those  that  are  general  or  constitutional.  Thus  the  super- 
ficial situation  of  the  tibia,  and  its  consequent  exposure  to  the 
vicissitudes  of  temperature,  are  thought  by  some  to  be  the  ex- 
planation of  its  greater  liability  to  necrosis ;  an  explanation 
which  will  certainly  stand,  in  those  cases  where  the  -disease 
follows  injury,  to  which  the  bone  is  more  liable  from  its  ex- 
posed situation.  Again,  the  condition  of  the  circulation  in  the 
lower  extremities,  as  influenced  by  standing,  exercise,  etc.,  is, 
doubtless,  often  a  predisposing  cause  of  bone  inflammation, 
and,  therefore,  sometimes  of  necrosis.  But  the  most  unequivo- 
cal of  the  predisposing  causes  are  those  which  may  be  termed 
constitutional.  In  the  scrofulous  and  in  the  syphilitic  there  is 
manifested  a  tendency  to  bone-disease;  in  fact,  a  predisposition 
to  necrosis,  which  only  requires  a  slight  exciting  cause  for  its 
development.  Besides  these,  there  are  certain  slender,  deli- 
cate, feeble  persons  in  whom  no  syphillis  and  no  scrofula  can 
be  detected,  and  yet  who  show  a  proclivity  to  necrosis,  which 
is  evidenced  by  the  repeated  attacks,  perhaps  at  far-distant 
periods,  of  the  disease  in  various  situations,  and  provoked  by 
exciting  causes  so  insignificant  as  often  to  leave  us  in  doubt 
whether  the  affection  might  not  be  regarded  as  spontaneous. 
To  these  oufjht  to  be  added  those  enfeebled  conditions  of  the 


122  DISEASES  OF  BONE. 

system  which  are  understood  to  favor  mortification,  such  as  the 
condition  induced  bj  long  exposure,  privation,  and  hardship, 
and  particularly  the  condition  following  severe  and  exhaustive 
diseases,  as  scurvy,  typhoid  fevers,  and  such  other  disorders  as 
may  be  presumed  to  diminish  the  power  of  the  circulation  to 
maintain  itself  against  the  sudden  assault  of  inflammation. 

With  these  predispositions,  both  local  and  general,  the  ex- 
citing causes  of  necrosis  may  be  enumerated  as — 

1.  Exposure  to  Wet  and  Cold. — I  believe  this  to  be  a  very 
common  cause  of  the  disease.     It  would  seem  as  if  exposure  to 
mere  cold,  while  it  has  great  influence  in  producing  superficial 
mortification,  did  not  especially  compromise  the  bones ;  while 
the  combination  of  wet  and  cold  is  one  of  the  most  common 
causes  of  inflammation  in  the  osseous  structures.     The  modus 
operandi,  on  the  bones,  of  this  particular  exposure  is  not  more 
easily  explained  than  the  action  of  the  same  cause  in  producing 
catarrh,  bronchitis,  or  rheumatism.     All  that  can  be  said  is, 
that  it  seems  to  be  an  analogous  process  in  the  case  of  the 
bones,  intensified  by  the  fact  that  the  bones  most  liable  to 
suffer  are  those  most  liable  to  direct  exposure  to  the  injurious 
cause,  as  the  bones  of  the  feet  and  the  shaft  of  the  tibia.     It 
would  seem,  also,  that  the   exposure  must  be   prolonged  in 
order  to  produce  its  effect,  for  we   find   that   most  patients 
report  their  attack  as  having  come  on  after  long  tramping 
through  snow  and  slush,  or  after  bathing  too  long  in  rather 
cold  water,  or  some  such  exposure  as  has  been  prolonged  suffi- 
ciently to  act  as  an  exhauster  of  the  general  power  of  resist- 
ance, as  well  as  a  depressor  of  the  local  circulation  of  the  part 
about  to  be  affected. 

2.  Injury. — In  a  variety  of  ways  injury  may  serve  as  the 
starting-point  of  a  bone-inflammation,  which  shall  terminate 
in  necrosis.     Contusions,  lacerations,  punctures,  detachments 
of  periosteum;  fractures,  strains,  bendings,  and  crushing  of 
the  bone  itself;  lacerations  and  exposures  of  the  medulla  are 
all  causes  of  inflammation  of  bone,  which  may  take  any  one  of 
the  many  courses  which  in  such  cases  is  determined  by  the 
constitution  and  the  surroundings  of  the  patient.     As  a  direct 
and  immediate  cause  of  death,  injury  does  not  often  act.    It  is, 
rather,  by  setting  up  of  inflammatory  actions,  which,  by  un- 


NECROSIS.  123 

favorable  influences,  shall  be  so  modified  as  ultimately  to  pro- 
duce a  fatal  effect  that  injury  acts ;  and  thus  we  may  consider 
violence  as  rather  the  indirect  and  secondary,  than  as  the 
direct  and  immediate,  cause  of  necrosis.  The  inflammations 
which  follow  injury  to  bones  are  generally  localized  about  the 
injured  parts,  and  are  moderate  in  their  accession,  so  that  it  is 
not  till  suppuration  has  taken  place,  or  exposure  to  the  air  has 
occurred,  that  we  find,  as  an  ultimate  result,  that  a  limited 
necrosis  has  taken  place.  This  is  well  illustrated  in  certain 
compound  and  comminuted  fractures,  where  the  injury  to  the 
bone  is  about  as  severe  as  it  can  be,  and  yet  where,  if  the  frac- 
ture behave  otherwise  well,  we  expect  no  necrosis  to  occur; 
and  it  is  only  after  long  suppuration,  and  perhaps  denudation 
of  periosteum,  and  exposure  of  the  bone  to  the  air,  and  to  the 
putrefying  discharges  of  the  wound,  that  we  find  a  small  por- 
tion of  the  end  of  the  broken  fragments  has  fallen  into  necro- 
sis. But  besides  these  cases  which  may  represent  the  behavior 
of  bone  after  injury  in  a  healthy  condition  of  the  system,  and 
under  favorable  circumstances,  there  are  a  certain  number  in 
which — a  strong  predisposition  to  bone  disease  existing — a  mod- 
erate injury  will  be  the  starting-point  of  severe  and  destructive 
inflammation,  rapidly  terminating  in  necrosis.  Here  the  ex- 
citing plays  so  much  less  important  a  part  than  the  predis- 
posing cause,  that  it  is  often  difficult,  as  before  remarked,  to 
be  sure  that  the  injury  has  had  any  thing  to  do  with  the  pro- 
duction of  the  mischief. 

3.  Mercury. — The  stomatitis  resulting  from  the  use  of  mer- 
cury sometimes  involves  the  bones  of  the  jaws  in  its  progress. 
The  action  here  is  more  frequently  that  of  caries  than  of  ne- 
crosis, mainly  because  the  alveolar,  rather  than  the  compact 
tissue  of  the  bone,  is  attacked.  "We  do,  however,  occasionally 
find  that  the  inflammation  creeps  along  the  periosteum,  sepa- 
rating that  membrane  from  the  bone,  and  producing  actual 
necrosis,  generally  of  a  limited  portion  of  the  jaw-bones.  I 
do  not  know  that  I  have  seen  a  general  or  even  an  extensive 
necrosis  from  this  cause,  the  most  considerable  having  been 
observed  in  cases  where  cancrum  oris  has  existed  as  the  pri- 
mary disease,  whose  dependence  on  the  influence  of  mercury 
has  been  more  than  questionable. 


124  DISEASES  OF  BOXE. 

4.  Phosphorus. — Dr.  Heyfelder,  of  Nuremberg,  first  called 
attention  to  the  fact  that  the    operatives   in   match-factories 
were  liable  to  a  peculiar  form  of  necrosis  of  the  lower  jaw. 
His  observations  were  published  in  1845,  and  since  that  time 
the  disorder  has  attracted  the  attention  of  surgeons  in  all  parts 
of  the  world,  and  much  recorded  experience  has  accumulated, 
giving  us  a  tolerably  complete  idea  of  its  pathological  as  well 
as  its  clinical  history.      It  is  undoubtedly  produced  by  the 
prevalence,   in   the   air  which   the   sufferers  have  long  been 
breathing,  of  the   fumes   of  phosphorus.      These   fumes   are 
mostly  in  the  shape  of  phosphorous  acid,  which  is  generated 
when   phosphorus  is    burnt    in    atmospheric  air.      How  this 
vapor  acts — whether  by  being  absorbed  into  the  system,  and 
acting  through  the  general  circulation,  or  whether  its  action  is 
local,  producing  its  effects  by  coming  in  direct  contact  with  the 
parts  liable  to  be  poisoned  by  it — is  a  question  upon  which 
much  difference  of  opinion  has  existed.      It  is  possible  that 
both  modes  of  action  may  be  combined ;  but  one  fact,  which 
points  very  strongly  to  the  local  character  of  the  cause,  is  found 
in  the  statement  that  those  operatives  who  have  sound  teeth 
are  rarely  affected  with  the  disease,  while  those  who  have  un- 
sound, carious  teeth,  or  spongy  gums,  are  extremely  liable  to  be 
attacked,  and,  in  particular,  it  is  stated  than  any  who  are  ex- 
posed to  the  phosphorus-fumes  soon  after  the   extraction  of  a 
tooth  are  almost  certain  to  suffer.     This  would  seem  to  render 
it  probable '  that  phosphorus,  or  rather,  perhaps,  phosphorous 
acid,  has  a  direct  poisonous  effect  upon  the  jaw-bones,  and  this 
poisonous  effect  must  be  much  increased  by  the  solubility  of 
the  gas  in  the  fluids  of  the  mouth,  by  which  the  poison  is  not 
only  concentrated,  but  brought  into  easy  contact  with  all  parts 
of  the  buccal  mucous  membrane,  acting  therefore  with  peculiar 
intensity  wherever  the  protection  of  the  epithelium  is  removed 
by  ulceration,  or  where  any  breach  of  surface  lets  the  poisoned 
fluid  into  contact  with  the  bone-tissues  to  which  it  holds  so 
mortal  an  enmity.   Why  the  Schneiderian  membrane,  which,  in 
the  same  manner,  and  at  least  to  an  equal  degree,  is  exposed 
to  the  poisonous  fumes,  is  not  liable  to  equal  injury,  it  is  not 
easy  to  explain. 

5.  Syphilis. — Many  of  the  secondary  and  tertiary  symp- 


NECROSIS.  125 

toms  of  syphilis  manifest  themselves  on  the  periosteum,  pro- 
ducing often  a  separation  between  that  membrane  and  the  bone, 
which  is  followed  by  a  necrosis.  There  are  also  cases  where,  in 
the  progress  of  the  dreadful  ulceration  which  syphilis  sometimes 
produces  in  the  facial,  buccal,  palatine,  and  nasal  regions, 
large  portions  of  the  subjacent  bone  die,  and  are  separated  en 
masse.  Still  further,  there  is  a  form  of  syphilitic  disease  of 
the  skull-bones  where  the  action  terminates  in  the  death  of  a 
portion  of  the  bone,  and  this  death  creeps  slowly  and  grad- 
ually over  such  extensive  districts  of  the  skull,  that  in  some 
instances  almost  the  whole  vault  of  the  cranium  is  finally  in- 
volved in  the  destruction.  In  these,  and  in  some  other  less 
marked  cases,  the  poison  of  syphilis  seems  to  be  directly  re- 
sponsible for  the  destruction  of  the  bone,  and  this  is  made  more 
evident  by  the  fact,  hereafter  to  be  more  particularly  studied, 
that  most  of  these  cases  of  syphilitic  necrosis  have,  in  their 
history,  features  which  are  quite  different  from  the  ordinary 
manifestations  of  the  disease,  and  which  are  entirely  character- 
istic of  the  action  of  a  specific  poison. 

6.  Fevers. — It  is  popularly  believed  that  fevers  do  frequent- 
ly produce  necrosis,  and  hence  one  popular  name  of  the  disease, 
viz.,  fever-sore.  It  certainly  is  observed  that,  after  an  attack 
of  fever,  necrosis  declares  itself;  and  it  must  be  acknowledged 
that  the  depressed  condition  of  the  system,  which  exists  during 
and  after  long-continued  and  severe  fever,  is  a  predisposing 
cause  strongly  favoring  the  occurrence  of  the  disease.  I  am 
not,  however,  prepared  to  say  that  it  is  a  common  result  of  the 
idiopathic  or  of  the  specific  fevers.  In  my  own  experience,  I 
have  been  a  little  surprised  that  I  have  been  so  rarely  able  to 
trace  necrosis  as  a  sequel  to  any  regular  form  of  fever,  as  ty- 
phus or  scarlatina,  the  history  of  which  has  been  distinct  and 
unequivocal.  Eather,  I  am  inclined  to  believe  that,  in  most 
cases,  where  this  disease  has  been  said  to  have  followed  a  fever, 
it  has  been  one  affection  from  the  beginning,  and  that  affection 
has  been  an  osteitis  terminating  in  necrosis;  the  earlier  stages 
of  the  disease  being  characterized  by  fever,  more  or  less  con- 
tinued in  type,  during  which  the  local  symptoms  were  either 
unusually  slight,  or  were  overlooked,  and  in  which,  the  fever 
abating  when  the  abscess  had  discharged  itself,  the  local  disease 


126  DISEASES   OF  BONE. 

came  to  be  considered  as  the  consequence  of  the  fever  of  which 
it  was  in  reality  the  cause.  That  this  is  the  case  in  a  large 
majority  of  so-called  fever-sores,  I  feel  very  confident ;  that  it 
is  uniformly  so,  I  will  not  positively  assert. 

The  seat  of  necrosis  varies  very  greatly.  Mostly  confined 
to  the  compact  tissue  of  the  long  bones,  it  may  aifect  the  can- 
cellous  in  any  part  of  the  skeleton.  Of  the  cases  in  which  the 
cancellous  tissue  is  the  seat  of  proper  necrosis,  I  think  the 
greater  part  will  be  found  to  be  instances  in  which  the  affec- 
tion has  been  associated  with  caries,  and  in  which,  therefore, 
the  necrosis  is  a  secondary  rather  than  a  primary  feature  of  the 
disease.  This  is  the  fact  with  a  great  many  cases  of  those  ul- 
cerations  of  the  bone,  with  necrosis,  which  accompany  the  ad- 
vanced stage  of  joint  destruction,  and  it  is  sometimes  observed 
that  a  small  sequestrum  of  the  cancellous  tissue  of  the  articu- 
lar end  of  a  bone  is  a  fatal  element  of  a  joint  disease,  which 
might  otherwise  prove  manageable.  There  are,  however,  a  cer- 
tain number  of  cases  in  which  the  death  of  the  spongy  tissue 
is  the  primary  element  of  the  disorder,  and  in  which  necrosis, 
commencing  thus,  presents  all  the  pathological  history  of  the 
disease  as  it  occurs  in  the  compact  tissue.  Of  this,  I  have 
seen  two  examples  in  the  os  calcis,  which  I  have' had  an  oppor- 
tunity to  verify  by  operation.  We  have,  in  the  New  York 
Hospital  Museum,  one  specimen  illustrating  this  fact,  in  the 
upper  end  of  the  humerus,  and  one,  a  syphilitic  specimen,  in 
the  lower  end  of  the  tibia.  Again,  it  is  often  observed  that 
the  cancellous  is  involved  with  the  compact  tissue  in  extensive 
examples  of  the  disease,  as  in  the  necrosis  of  the  shaft  of  the 
long  bones,  involving  some  of  the  expanded  extremity ;  and, 
in  the  spreading  form  of  necrosis  of  the  bones  of  the  cranium, 
the  diploe  does  not  seem  to  offer  any  material  check  to  the 
progress  of  the  necrosis,  becoming  itself  affected  almost  as 
rapidly  and  nearly  to  the  same  extent  as  the  external  table, 
which  seems  to  be  the  primary  seat  of  the  malady.  These, 
however,  it  must  be  noted,  are  only  offered  as  exceptional  facts, 
and  in  contrast  to  them  it  should  be  stated  that,  in  many  cases 
the  compact  tissue  dies,  while  the  cancellous  in  immediate  con- 
tact with  it  lives ;  and  thus  we  have  produced  those  tubular 
sequestra  in  which  the  outer  compact  shell  of  the  bone  only 


NECROSIS.  127 

has  died,  leaving  a  living  centre  or  axis  of  cancellous  tissue 
which  has  been  able  to  maintain  its  vitality.  This  I  have 
several  times  observed  in  those  cases  where  necrosis  declares 
itself  after  compound  fracture,  and  I  have  been  much  discon- 
certed to  find  that,  after  I  had  removed  the  most  superficial 
and  accessible  layer  of  dead  bone,  a  similar  layer  surrounded 
the  whole  shaft,  the  extraction  of  which  necessitated  a  long 
and  difficult  operation.  In  this  way  are  produced  the  varie- 
ties we  notice  in  the  extent  of  necrosis.  These  varieties  may 
be  classified  as — 1.  The  superficial.  2.  The  internal  or  central. 
3.  The  complete,  where  the  whole  thickness  but  not  the  whole 
length  of  the  shaft  is  involved.  4.  The  total,  where  the  en- 
tire bone  has  perished. 

It  is  interesting  to  observe,  in  this  connection,  that  certain 
bones  are  more  liable  than  others  to  the  disease.  Thus  we 
have,  according  to  Mr.  Stanley,  the  tibia  suffering  much  more 
frequently  than  any  other  bone.  The  femur  is  next  in  order, 
but  at  a  great  distance  from  the  tibia.  Then  we  have  the 
humerus,  flat  cranial  bones,  lower  jaw,  last  phalanx  of  finger, 
clavicle,  ulna,  radius,  fibula,  scapula,  upper  jaw,  pelvic  bones, 
sternum,  ribs.  This  peculiarity  of  the  tibia,  disposing  it  in  so 
eminent  a  degree  to  necrosis,  seems  to  be  most  marked  in  its 
upper  expanded  portion,  where  not  only  do  we  see  necrosis 
occurring  very  frequently,  but  many  forms  of  inflammation 
and  abscess,  and  a  large  proportion  of  the  malignant  as  well 
as  other  tumors  of  the  bone,  find  their  favorite  seat  in  this 
portion  of  the  tibia.  M.  Oilier  has  thrown  some  light  upon 
this  subject,  by  the  general  law  which  he  has  discovered,  that 
the  extremities,  both  of  the  femur  and  tibia,  which  form  the 
knee-joint,  have  in  themselves  a  much  greater  amount  of 
power  of  growth  and  development  than  the  other  extremities 
of  these  bones,  which  form  respectively  the  hip-  and  ankle- 
joints.  This  interesting  observation  has  many  practical  rela- 
tions, and,  among  others,  it  seems  to  explain  how  it  is  that  the 
head  of  the  tibia  plays  so  important  a  part  in  the  diseases  of 
the  skeleton  ;  being  more  highly  vitalized,  it  is  more  active  in 
all  the  processes  of  health,  and  therefore  probably  of  disease, 
than  other  portions  of  the  skeleton,  lower  in  the  scale  of  vital 
activity. 


128  DISEASES   OF  BONE. 

In  proceeding  now  with  the  further  study  of  necrosis,  it 
will  be  convenient  to  take  a  typical  example  of  the  disease,  say 
a  case  occurring  in  a  young  healthy  person,  in  the  shaft  of  the 
tibia,  and  of  moderate  extent,  and  make  it  the  basis  of  system- 
atic study.  In  pursuance  of  this  study  we  shall  have  to  notice 
— 1.  The  pathological  conditions  and  changes  which  the  case 
presents.  2.  The  symptoms  accompanying  and  characterizing 
these  conditions.  3.  The  treatment  appropriate  to  each  stage. 

1.  The  Pathological  Conditions. — The  first  condition  which 
can  be  recognized  in  a  case  of  commencing,  necrosis  is,  without 
doubt,  one  of  inflammation,  involving,  we  will  suppose,  the 
greater  part  of  the  shaft.  I  do  not  know  of  any  observations 
which  have  thrown  any  light  on  this  pcint  in  the  human  sub- 
ject, but.  reasoning  from  what  is  observed  in  experiments  upon 
animals,  it  seems  probable  that  the  whole  bone  partakes  more 
or  less  of  the  inflammatory  congestion,  of  which  the  central 
part  of  the  shaft  is  to  be  the  principal  seat.  This  inflammatory 
congestion  probably  is  manifested  most  distinctly  by  the  ves- 
sels of  the  periosteum,  and  Try  those  of  the  medulla.  "Whether 
any  increased  vascularity  can  be  appreciated  by  the  eye  in  the 
compact  substance  of  the  bone,  I  cannot  affirm.  In  the  portion 
which  dies  under  this  inflammatory  effort,  no  further  obvious 
change  occurs.  The  circulation  ceases,  and  the  section  of  bone 
is  no  longer  associated  in  any  of  the  vital  changes  which  go  on 
about  it.  The  dead  portion  of  bone,  or  sequestrum,  as  it  is 
called,  very  shortly  becomes  of  a  uniform,  pale,  waxy,  yellow- 
ish-white color,  differing  very  slightly  and  yet  distinctly  from 
the  color  of  living  bone ;  a  difference  which,  I  think,  is  some- 
what exaggerated  by  maceration  and  drying  of  the  bone,  under 
which  condition  we  most  commonly  see  it.  During  all  the 
further  changes  of  the  disease,  the  sequestrum  undergoes  no 
change  of  appearance,  except  that  it  may  be  accidentally 
tinged  by  exposure  to  the  various  fluids  and  gases  developed 
about  it.  The  most  common  of  these  accidental  colorations  of 
the  sequestrum  is  the  brownish  black  which  it  sometimes  pre- 
sents, where  it  has  long  been  exposed  to  the  air,  in  such  a  way 
that  the  surface  shall  be  alternately  wet  and  dry.  This,  mainly 
a  surface  color,  stops  abruptly  at  the  point  where  tli3  seques- 
trum is  constantly  covered  over  by  soft  parts,  and  is  so  abiding 


NECROSIS.  129 

that  prolonged  maceration  will  scarcely  remove  it.  What  the 
chemical  nature  of  the  change  is  I  do  not  know ;  but  one  would 
naturally  suspect  the  hydrosulphuric  acid,  generated  in  the  de- 
composition of  the  pus,  to  be  the  active  agent  in  its  production. 

The  actions  which  accompany  this  death  of  a  portion  of  a 
bone  in  the  surrounding  living  textures  are  more  interesting, 
more  distinct,  and  more  important.  The  outline  separating 
the  dead  from  the  living  bone  is  extremely  irregular,  made  so 
by  the  fact,  probably,  that  each  vascular  twig  does  not  fail  to 
maintain  itself  at  precisely  the  same  level,  some  sustaining  life 
a  little  further  or  a  little  longer  than  their  neighbors.  The 
unevenness  of  outline  thus  produced  is  rather  more  marked  in 
the  cancellous  than  in  the  compact  substance  of  the  bone,  and 
gives  to  the  extremities  of  the  sequestrum,  where  they  encroach 
upon  the  cancellous  tissue,  a  particularly  irregular,  fissured, 
and  branched  outline.  When  the  separation  takes  place 
through  hard  bone,  it  is  sometimes  quite  smooth  and  even  in  its 
outline.  The  part  of  the  bone  covered  by  periosteum  presents 
usually  a  more  even  and  natural  surface.  Here  the  line  of 
separation  is  accurately  between  the  periosteum  and  the  bone, 
so  that  the  sequestrum  is  just  as  smooth  and  regular  as  the 
natural  bone  would  have  been  if  macerated  ;  while,  at  the 
points  where  dead  and  living  bone  have  separated,  it  is,  as 
stated  before,  extremely  irregular  and  uneven. 

The  action  of  separation  is  accomplished  by  a  process  of 
molecular  death,  and  the  removal  of  the  particles  of  living 
tissue  next  in  contact  with  those  which  have  died.  These  par- 
ticles are  removed  by  the  vessels  of  the  living  part,  by  a  pro- 
cess of  absorption,  which,  in  healthy  and  young  subjects,  goes 
on  with  considerable  rapidity.  Much  doubt  formerly  existed 
on  this  subject,  whether  the  line  of  separation  was  at  the  ex- 
pense of  the  living  or  dead  bone ;  a  doubt  that  had  this  prac- 
tical importance,  that  it  left  unsettled  the  question  as  to 
whether  the  sequestrum  is  capable  of  removal  by  absorption. 
Mr.  Hunter  showed  clearly  that  the  action  took  place  on  living 
particles  only,  the  dead  taking  no  part  in  the  process ;  and 
this  view,  so  entirely  in  consonance  with  our  ideas  of  patholo- 
gical action  in  other  tissues,  is  now  universally  accepted. 
Whether  all  the  bone-matter  is  removed  by  absorption,  or 
9 


130  DISEASES   OF   BONE. 

whether  some  portion  of  it  is  cast  off  in  the  discharges,  is 
another  question  of  some  interest,  perhaps  more  pathological 
than  practical.  Mr.  Bransby  Cooper's  observations  go  to  show 
very  distinctly  that  pus,  in  the  neighborhood  of  diseased  and 
exfoliating  bone,  contains  much  more  than  its  usual  proportion 
of  phosphate  and  carbonate  of  lime,  leading  to  the  inference 
that  a  portion  at  least  of  the  bone-matter  was  thrown  off  by 
the  pus.  These  observations  of  Mr.  Cooper's,  which  have  been 
much  quoted,  are  not  published  in  full  detail,  the  paper  in  the 
Medical  Gazette,  for  the  year  1845,  being  merely  a  sketch  of  a 
lecture  given  by  Mr.  Cooper  on  these  subjects,  and  are  imper- 
fect, as  far  as  relates  to  our  point,  in  not  specifying  the  nature 
of  the  diseases  of  the  bones  on  which  the  observations  were 
made.  While,  therefore,  they  prove  that  pus  from  diseased 
bone  contains  an  unusual  proportion  of  the  elements  of  bone, 
there  is  nothing  in  these  observations  to  show  that  exfoliation 
is  accomplished  by  any  other  than  a  process  of  absorption. 
Indeed,  the  microscope  makes  it  pretty  clear  that  it  is  a  pure 
act  of  absorption ;  for  all  observers  agree  that  the  first  step 
in  the  process  is  a  removal  of  the  earthy  matters  from  the  bone- 
tissue,  which  is  about  to  be  the  seat  of  the  change ;  and  subse- 
quently to  that  removal,  while  the  bone  is  in  the  condition  of 
fibrous  tissue,  the  real  ulcerative  or  absorptive  process  goes 
on.  This  being  the  case,  it  would  hardly  seem  likely  that,  as 
the  ulceration  is  progressing  in  a  tissue  deprived  of  its  earthy 
constituents,  any  of  those  earthy  constituents  could  be  found 
in  the  discharges.  The  act  of  separation  begins  at  the  surface 
of  the  bone,  and  proceeds  in  depth,  till  the  whole  interval  be- 
tween the  dead  and  living  tissue  presents  a  space,  generally  of 
one  or  two  lines  in  width,  so  that,  when  the  process  is  complete 
and  the  dead  bone  separated,  it  is  found  to  be  lying  loose  in  a 
space  or  cavity  which  is  considerably  too  large  for  it,  and  in 
which,  therefore,  it  can  be  moved  about  sufficiently  to  indicate 
to  the  surgeon,  by  this  mobility,  that  it  is  entirely  separated 
from  its  connections. 

The  surface  of  the  living  bone,  looking  toward  and  forming 
the  wall  of  the  cavity  in  which  the  sequestrum  lies,  corresponds 
pretty  accurately  with  the  general  outline  of  the  dead  portion ; 
and,  probably,  if  the  bone  were  macerated  immediately  after 


NECROSIS.  131 

separation  was  accomplished,  this  correspondence  would  be 
still  more  perfect ;  but,  as  has  been  remarked  above,  the  cavity 
is  larger  than  the  sequestrum  by  all  the  space  in  which  absorp- 
tion of  tissue  has  proceeded.  This  space  is  not  always  main- 
tained without  change ;  for  it  is  noticed  in  old  cases  that  the 
cavity  is  sometimes  much  larger  than  the  sequestrum,  though 
no  bone  has  been  discharged ;  and  our  present  views  forbid  us 
to  believe  that  the  dead  bone  can  undergo  any  alteration  in 
size.  It  would,  therefore,  seem  pretty  certain  that  this  en- 
largement is  caused  by  absorption,  provoked,  probably,  by  the 
movements  of  the  sequestrum,  or  by  its  pressure  at  particular 
points,  a  view  which  is  strengthened  by  the  fact  that  the  en- 
largement is  not  constant  nor  uniform,  in  some  cases  being 
only  at  limited  portions  of  the  cavity,  while  the  rest  embraces 
the  sequestrum  so  tightly  as  to  prevent  its  moving  freely,  even 
in  the  macerated  specimen. 

This  space  between  the  living  and  the  dead  bone  is  not  a 
vacuum  during  life,  though  it  appears  so  when  the  bone  is 
dried.  It  is  occupied,  and  usually  pretty  accurately  filled,  by 
soft,  luxuriant  granulations,  which,  springing  up  from  the 
living  bone  on  all  sides,  form  a  bed  in  which  the  sequestrum 
lies,  and  by  which  its  injurious  contact  with  the  living  bone- 
tissue  is  prevented.  This  layer  of  granulation-substance,  in  a 
healthy  subject,  is  of  a  firm,  ruddy  appearance,  and  represents 
Nature's  endeavors  to  repair  the  mischief  which  has  occurred  ; 
which  endeavors  are  of  course  ineffectual,  on  account  of  the 
presence  of  what  has  now  become  a  foreign  body.  Never- 
theless, though  the  main  object  for  which  they  are  thrown  out 
fails  to  be  accomplished,  yet  the  secondary  purpose  of  protec- 
tion and  support  to  the  loose  sequestrum  is  scarcely  of  less  im- 
portance for  the  comfort  of  the  individual ;  and  it  is  worthy  of 
remark,  and  I  think  of  special  admiration,  that  this  admirable 
cushion  fulfils  its  duties  so  well,  that  the  patient  may  carry  a 
large  and  rough  sequestrum  for  many  years,  without  ever 
being  sensible  of  its  motions,  and  without  the  least  sensation 
of  suffering  from  its  contact  with  its  living  tissues.  This  arises 
from  the  fact  that  Nature  not  only  provides  this  soft  layer  of 
protecting  granulations,  but  makes  them  so  firm  and  so  callous 
in  their  endowments  that  they  are  entirely  insensible  to  any 


132  DISEASES  OF  BONE. 

painful  contact,  while  they  are  sufficiently  consistent  to  secure 
the  immobility  of  the  otherwise  loose  sequestrum. 

The  granulations  thus  lining  the  cavity  secrete  a  moderate 
quantity  of  pus,  which  finds  its  way  out  of  some  of  the  open- 
ings in  the  surrounding  bone.  In  a  healthy  person  this  dis- 
charge is  exceedingly  small  in  quantity,  amounting,  even  from 
a  large  cavity,  to  only  a  few  drops  in  twenty-four  hours. 
This,  however,  is  liable  to  the  greatest  variations,  both  in 
quantity  and  quality.  In  some  cases  the  discharge  is  so  con- 
stant and  profuse  as  to  be  in  itself  an  element  of  danger  to  the 
patient's  life ;.  and  there  are  others  where,  temporarily  at  least, 
it  ceases  altogether.  It  may  always  be  accepted  as  a  favorable 
sign,  when  this  discharge  is  small  in  quantity  and  healthy  in 
appearance ;  and  it  should  always  excite  apprehension  of  pro- 
gressive local  disease  \vhen  it  is  ill-conditioned  and  profuse. 
Mingled  with  this  pus,  blood  is  sometimes  seen,  doubtless  from 
the  friction  of  the  rough  sequestrum  against  the  granulations ; 
and,  when  it  is  from  this  source,  it  is  usually  in  very  moderate 
quantities.  Large  quantities  of  blood,  issuing  rapidly  from  a 
case  of  necrosis,  indicate  a  different  source  and  a  much  more 
serious  danger,  as  will  be  hereafter  particularly  explained. 

While  this  process  of  separation  has  been  going  on,  other 
changes  have  been  taking  place  in  the  surrounding  soft  parts, 
which  we  must  now  study.  Nature,  as  if  anticipating  the 
result  which  must  follow  the  separation  between  the  dead  and 
living  bone,  summons  up  her  reparative  activities  to  supply 
that  support  to  the  limb  which  is  about  to  be  destroyed  by  her 
own  hands ;  and,  long  before  the  actual  solution  of  continuity 
has  taken  place  in  the  shaft  of  the  bone,  we  find  that  the  com- 
pensatory strengthening  process  has  made  sufficient  progress 
to  prevent  any  evil  consequences  from  the  break.  This  pro- 
cess consists  essentially  in  an  ossification,  springing  from  the 
parts  surrounding  the  dead  bone,  which,  reaching  from  the 
living  bone  above  to  the  living  bone  below,  bridges  over  the 
breach,  and  forms  a  sort  of  ferule  of  new  bone,  which,  by  its 
abundance  and  perfect  organization,  more  than  supplies  the 
wanting  support.  Out  of  this  important  and  very  interesting 
process  grow  many  of  the  most  striking  features  of  the  disease 
we  are  studying,  both  clinical  and  pathological ;  and  it  may  even 


NECROSIS.  133 

be  affirmed  that  most  of  the  indications  for  and  the  success  of 
any  treatment  that  may  be  instituted  for  the  cure  of  the  mis- 
chief, must  be  founded  on  a  careful  consideration  of  this  action 
of  Nature,  and  that  upon  its  perfection  or  imperfection  will 
necessarily  depend  the  future  usefulness  of  the  member. 

It  is  now  generally  conceded  that  the  new  bone  is  derived 
from  four  different  sources,  viz.,  the  periosteum,  the  medulla, 
the  old  bone  in  immediate  proximity,  and  the  nearest  sur- 
rounding; soft  parts.  These  are  all  believed  to  contribute  their 
share  in  supplying  the  new  material,  but  under  very  varying 
circumstances ;  and  there  are  few  questions  upon  which  opin- 
ions have  been  more  fluctuating  and  contradictory  than  upon 
the  relative  efficiency  of  each  source  of  supply.  From  the 
time  of  Duhamel,  whose  first  memoir  was  published  in  1T39, 
the  opinions  of  most  of  those  who  have  made  this  a  subject  of 
study,  has  been  unequivocal  in  favor  of  the  periosteum  as  the 
principal  agent  in  this  ossification  ;  and  more  recently  M.  Oilier, 
of  Lyons,  has  demonstrated,  by  a  series  of  careful  and  well-con- 
ducted experiments,  fortified  by  abundant  observation  on  the 
human  subject  under  various  conditions  of  disease,  that  not  only 
is  the  periosteum  the  principal  source  of  ossific  supply,  where 
bone  has  been  removed  by  disease  or  operation,  but  that,  in  fact, 
the  other  parts  mentioned  play  a  very  subordinate  and  insig- 
nificant part  in  the  process.  M.  Oilier  conducted  his  experi- 
mental observations  on  dogs,  cats,  rabbits,  lambs,  pigeons, 
etc.,  and  carefully  studied  to  make  the  necessary  operations  in 
such  a  manner  as  to  interfere  with  his  results  as  little  as  pos- 
sible. In  this,  by  practice,  he  became  very  skilful,  and  hence 
his  operations  deserve  more  confidence  and  illustrate  more 
distinctly  the  points  he  wishes  to  make,  than  those  of  most  of 
the  experimenters  who  have  preceded  him.  Some  of  the  most 
important  deductions  of  M.  Oilier  are — 1.  That  the  periosteum 
is  the  great  source  of  reproduction  of  bone  under  all  ordinary 
circumstances.  2.  That  the  periosteum  presents  two  layers, 
an  inner  and  an  outer  one,  of  which  the  inner  alone  is  endowed 
with  the  bone-producing  power.  3.  That  the  medulla  is  not, 
under  ordinary  circumstances,  disposed  to  the  formation  of 
new  bone ;  but  that  it  is,  under  conditions  of  irritation,  capable, 
to  a  certain  extent,  of  such  production,  but  always  in  a  much 


134  DISEASES  OF  BONE. 

inferior  degree  to  the  periosteum.  4.  That  the  bone-substance 
itself  may  also  give  rise  to  a  growth  of  new  bone,  but  that  its 
powers  are  much  more  limited  than  those  of  the  medulla. 
5.  That  though  in  certain  exceptional  cases  the  surrounding 
soft  parts  can  accomplish  a  partial  bony  reproduction,  yet, 
practically  speaking,  such  reproduction  is  not  to  be  expected, 
when  the  whole,  or  a  portion  of  a  bone,  with  its  periosteum,  is 
removed.  These  views  of  M.  Oilier  are  so  nearly  in  accord- 
ance with  the  opinions  of  the  best  observers  who  have  pre- 
ceded him,  and  are  so  well  defended  in  his  work,  that  I  think 
they  may  be  accepted  as  expressing  the  view  most  generally 
received  on  this  subject,  and  as  being  as  near  the  truth  as  the 
present  state  of  science  permits  us  to  arrive.  Nevertheless, 
there  are  not  wanting  those  who  differ  from  him  toto  coelo.  Of 
recent  observers,  Marmy,  of  Lyons,  quoted  by  M.  Oilier,  asserts 
that  in  his  experiments  he  has  succeeded  better  in  procuring  a 
reproduction  of  lost  bone  by  removing  than  by  preserving  the 
periosteum ;  and  Hein,  of  Dantzic,  though  he  does  not  deny 
the  utility  of  the  periosteum,  thinks  that  the  surrounding  tis- 
sues may  very  well  replace  it. 

In  the  case  of  necrosis,  which  we  are  now  studying,  we 
will  suppose  that  the  whole  of  the  middle  portion  of  the  shaft 
has  perished.  In  such  a  case,  the  dead  portion  is  immediately 
surrounded  by  its  periosteum,  and  in  contact  above  and  below 
with  the  living  portions  of  the  shaft,  the  medulla  being  sup- 
posed to  have  perished  with  the  bone.  We  have  here,  there- 
fore, only  two  sources  from  which  the  supply  of  new  bone  can 
be  derived,  viz.,  the  periosteum  and  the  adjacent  old  bone.  It 
is  observed  of  the  periosteum  that  it  soon  begins  to  vascnlar- 
ize,  and  take  on  granulation  action  by  its  internal  surface, 
which  surface  is  separated  by  these  granulations  from  contact 
with  the  sequestrum.  "We  have  already  seen  that,  at  the 
point  where  the  dead  separates  from  the  living  bone,  the  sur- 
face of  the  living  bone  becomes  also  covered  with  a  layer  of 
granulations.  It  is  in  these,  probably,  that  the  further  changes 
occur.  It  was  formerly  held  that  these  granulations  were  the 
forming  stage  of  an  exudation  or  plasma,  thrown  out  in  a  fluid 
state,  which,  coagulating,  developed  itself  into  the  new  bone. 
Yirchow  has  shown  that,  at  least  in  many  examples,  such  ex- 


NECROSIS.  135 

udation  does  not  occur,  and  his  theory  is,  that  there  is  no  such 
thing  as  spontaneous  organization  of  living  forms  in  any  ex- 
uded fluid,  but  that  such  actions  are  to  be  referred  to  a  growth 
or  proliferation,  as  he  terms  it,  of  germs  which,  already  exist- 
ing in  the  tissue,  assume  the  actions  of  increase  and  develop- 
ment under  certain  conditions  of  excitation.  Whether  Yir- 
chow's  views  are  to  be  accepted  in  all  their  extent,  or,  indeed, 
whether  they  are  applicable  to  the  question  before  us,  need  not 
now  be  insisted  on ;  but  it  is  somewhat  interesting  to  observe 
that,  after  the  lapse  of  more  than  a  century,  Duhamel's  original 
idea,  that  the  periosteum  itself  is  converted  into  the  new  bone, 
is  so  nearly  identical  with  that  which  the  distinguished  Berlin 
professor  now  so  strongly  and  so  ably  advocates. 

The  periosteum  then  gradually  becomes  thickened  and  vas- 
cularized,  and  on  its  internal  aspect  begin  to  be  seen  the  first 
traces  of  ossification.  This  action,  it  must  be  remembered, 
begins  very  early  in  the  case,  and  may  be  considered  to  be 
complete  generally  in  the  same  space  of  time  that  is  occupied 
by  the  separation  of  the  dead  from  the  living  bone.  Large 
quantities  of  new  bone  are  deposited  thus  round  the  seques- 
trum, until  finally  it  becomes  enclosed  in  a  casing  of  new  bone 
which  is  in  reality  much  more  bulky  and  much  stronger  than 
the  original  bone,  whose  loss  it  is  intended  to  replace  (Fig.  18). 
The  pus  which  is  secreted  from  the  granulation  surface  finds  its 
way  out  through  fistulous  openings,  at  various  points  in  the 
periosteum ;  and,  as  new  bone  is  not  deposited  at  these  open- 
ings, they  remain  as  outlets  through  the  bony  casing  by  which, 
through  fistulse  reaching  to  the  cutaneous  surface,  the  pus  finds 
exit.  These  openings  are  termed  cloacre  (Fig.  19). 

While  this  action  is  taking  place  in  the  periosteum,  the 
bone-tissue,  which  borders  on  the  cavity  containing  the  seques- 
trum, is  presenting  analogous  phenomena.  It  is  becoming  vas- 
cularized,  and  giving  origin  to  granulations  which  have  a  ten- 
dency, when  the  sequestrum  is  removed,  to  be  converted  into 
bone,  and  thus  assist  in  filling  up  the  vacuity  which  has 
occurred.  It  is  noticed,  however,  that  this  action  is  extremely 
limited,  and  by  itself  constitutes  a  very  unreliable  source  of 
supply.  In  cases  where  the  periosteum  is  not  preserved,  the 
amount  of  new  growth,  from  the  ends  of  the  living  bone,  will 


136 


DISEASES   OF  BONE. 


not  serve  even  to  unite  the  extremities  of  the  gap,  much  less 
to  fill  it  up.  In  cases,  again,  where  the  periosteum  is  preserved 
and  contributes  its  usual  share  to  the  filling  up  of  the  cavity, 


FIG.  18.— (From  Billroth.) 


FIG.  19.— (From  Erichsen.) 


the  new  bone  which  it  deposits,  and  that  which  comes  from  the 
ends  of  the  old  bone,  are  so  amalgamated  together,  that  the 
share  of  each  cannot  be  recognized,  and  it  is  only  by  observing 
those  cases  in  which  the  periosteum  does  not  enter  into  the 
reparative  action,  that  we  can  distinctly  see  how  very  limited 
a  power  of  producing  new  bone  is  exhibited  by  the  old  bone  in 
its  neighborhood. 


NECROSIS. 


137 


The  sequestrum  being  thus  separated,  and  the  loss  being 
repaired,  or  rather  compensated  for,  by  the  growth  of  new- 
bone,  the  getting  rid  of  the  sequestrum  is  the  next  point  which 
demands  our  attention.  In  those  forms  of  necrosis  where  the 
dead  portion  is  small  and  superficial,  there  is  usually  no  en- 
closure of  the  sequestrum  within  the  involucrum  in  such  man- 
ner as  to  prevent  its  extrusion ;  so  that  no  mechanical  obstruc- 
tion prevents  its  being  cast  out.  We  usually  observe,  there- 
fore, in  such  cases,  that,  as  soon  as  it  is  entirely  loose,  the  se- 
questrum begins  to  make  its  way  to  the  surface,  in  obedience 
to  a  law  by  which  foreign  bodies,  lodged  in  the  tissues,  find 
their  way  toward  the  nearest  surface  by  which  they  can  con- 
veniently be  discharged.  The  process  seems  to  be  one  in  which 
the  granulations  press  on  it  behind,  and  are  absorbed  before  it 


FIG.  20.— {From  Billroth.) 


in  such  a  way  that  it  gradually  works  toward  the  surface,  and 
finally  projects  at  one  of  the  fistulous  openings,  whence  it  is 
easily  withdrawn  (Figs.  20  and  21).  This  disposition  of  these 
small  sequestra  may  serve  to  indicate  to  us  the  intentions  of 


FIG.  21.— (From  Billroth.) 


Nature  with  regard  to  the  larger  ones,  which  we  are  now  par- 
ticularly studying.  The  intention  undoubtedly  is  to  extrude 
the  larger  as  well  as  the  smaller  sequestra,  and  the  extrusion 


138  DISEASES  OF  BONE. 

would,  I  doubt  not,  be  more  often  accomplished  if  it  were  not 
for  the  mechanical  obstacle  which  is  presented  by  the  unyield- 
ing involucrum  in  which  the  dead  bone  is  imprisoned.  Exam- 
ples are  not  unfrequent  in  our  museums  of  large  sequestra 
which  are  gradually  liberating  themselves  from  imprisonment, 
and  projecting  themselves  toward  the  surface.  This  course  is, 
perhaps,  sometimes  determined  by  a  large  and  favorably-situ- 
uated  cloaca,  or  possibly  by  a  partial  absence  of  involucrum 
at  a  certain  point ;  but  while  it  may  not  often  serve  to  free  the 
patient  from  his  encumbrance,  it  does  certainly  show  that  there 
is  probably  in  all  cases  a  tendency,  more  or  less  decided  as  it  is 
more  or  less  resisted,  to  the  spontaneous  extrusion  of  sequestra. 
This  action,  though  conservative  in  its  intention,  is  not  with- 
out its  dangers  and  inconveniences.  We  have,  in  our  museum 
at  the  college,  a  specimen  in  which  such  a  sequestrum,  thus 
partially  extruded,  has  eroded  the  popliteal  artery,  causing  the 
death  of  the  patient  from  haemorrhage  ;  and  I  have  seen 
another  case  in  which  destruction  of  the  knee-joint,  with  com- 
pete bony  anchylosis,  was  produced  by  a  similar  cause.  While, 
therefore,  it  is  important  to  recognize  the  fact  that  there  is  a 
tendency  toward  the  throwing  off  of  these  foreign  masses,  by 
Nature's  spontaneous  actions,  yet  it  will  be  found  that  in 
practice  not  much  can  be  expected  from  her  efforts  ;  and,  as  a 
general  rule,  it  may  be  stated  that,  where  the  sequestrum  is 
enclosed  in  a  bony  involucrum,  surgical  assistance  is  required 
to  remove  the  mechanical  resistance  to  its  expulsion.  Where 
this  assistance  is  withheld,  the  case  will  pass  on  for  years,  even 
for  a  long  lifetime,  without  any  material  change  either  in  the 
condition  or  the  position  of  the  sequestrum,  which  has  now  be- 
come the  mere  mechanical  cause  of  the  symptoms  under  which 
the  patient  will  thus  long  continue  to  suffer.  Of  this  imprison- 
ment of  the  sequestrum  within  the  involucrum,  Fig.  19,  taken 
from  Erichsen's  surgery,  is  a  good  example,  though  the  cloacae 
are  commonly  much  smaller,  and  the  imprisonment  therefore 
more  complete,  than  here  exhibited. 

The  symptoms  which  characterize  these  different  stages  of 
necrosis  may  be  studied  as  belonging  to  the  three  periods  in  the 
pathological  changes,  which  we  may  mark  as — 1.  The  period 
of  inflammation,  by  which  the  necrosis  is  originally  produced  ; 


NECROSIS.  139 

2.  The  period  of  sequestration,  during  which  the  separation  is 
proceeding  and  the  involucrum  being  formed  ;  and  3.  The  pe- 
riod of  retention,  during  which  the  sequestrum  remains  as  a 
foreign  body  within  the  involucrum. 

1.  The  inflammation  which  produces  such  a  necrosis  as  we 
have  chosen  for  our  type  of  the  disease  is  almost  invariably 
an  acute  attack.  At  a  certain  period,  after  the  action  of  some 
of  the  causes  we  have  noticed  above,  pain  and  swelling  attack 
the  limb,  which  soon  becomes  the  seat  of  severe  and  manifest 
phlegmonous  inflammation.  The  whole  limb  (the  leg,  for  ex- 
ample) is  involved  in  this  inflammation,  which  indeed  often 
extends  to  the  foot  below,  and  to  the  thigh  above.  For  this 
reason  it  is  often  difficult,  in  the  early  stages,  to  decide  accu- 
rately where  the  effects  of  this  violent  and  extensive  action  are 
to  concentrate  themselves.  It  is  in  this  stage  that  most  of  the 
mistakes  are 'made  by  practitioners  of  limited  experience,  and 
the  disease  is  looked  upon  as  erysipelas,  simple  phlegmon,  or 
rheumatism,  until  the  progress  of  the  case  throws  light  upon 
its  nature.  No  man  can  with  certainty  pronounce  a  positive 
diagnosis,  in  all  cases  of  inflammation,  which  are  to  terminate 
in  necrosis ;  but  the  possibility  of  such  a  chain  of  symptoms, 
depending  on  osteitis,  leading  to  necrosis,  being  borne  in  mind, 
it  is  not  likely  that  the  careful  observer  will  long  be  deceived. 
This  inflammation  occurring,  as  it  does,  in  young  and  some- 
times vigorous  subjects,  passes  through  its  stages  rapidly,  and 
soon  terminates  in  suppuration.  We  have  seen  that  the  first 
exudations  probably  take  place  between  the  periosteum  and 
the  bone.  It  is  here,  also,  that  suppuration  begins,  and,  sepa- 
rating the  periosteum  from  the  bone,  distends  that  membrane 
as  far  as  its  unyielding  nature  will  permit.  This  is  the  period 
which  is  accompanied  by  the  most  urgent  symptoms  of  fever 
and  pain  ;  and  when  the  periosteum  gives  way,  and  the  matter 
escapes  into  the  surrounding  soft  parts,  the  severity  of  the  suf- 
fering is  somewhat  relieved.  Through  these  soft  parts,  which 
participate  in  the  general  inflammation,  the  matter  makes  its 
way  to  the  surface,  sometimes  only  after  having  accumulated 
to  a  very  large  extent.  Naturally  or  artificially  the  pus  is 
finally  evacuated,  and  the  first  stage  may  be  regarded  as  ter- 
minated. This  stage  is  marked  by  very  severe  constitutional 


140  DISEASES  OF  BONE. 

disturbance,  very  high  inflammatory  fever,  and  active  delirium, 
sometimes  existing  during  all  the  earlier  days  of  the  attack. 
This  fever  with  delirium  is  often  mistaken  for  typhoid  fever — 
the  delirium  masking  the  local  complaint,  so  that  attention  is 
not  called  to  the  suffering  limb,  till  inflammation  has  made 
extensive  progress.  When  the  pus  is  evacuated,  a  sensible  im- 
provement occurs  in  the  general  symptoms,  as  well  as  in  the 
local  sufferings.  The  fever  abates  rapidly,  the  pains  cease  in 
a  great  degree,  the  great  swelling  subsides,  and  every  thing 
seems  rapidly  returning  to  a  condition  of  health.  Here,  again, 
a  false  hope  is  apt  to  be  entertained  that  the  cure  of  the  ab- 
scess will  be  the  cure  of  the  disease,  and  the  patient  is  flattered 
that  he  will  soon  be  entirely  well.  Instead  of  this,  however, 
it  is  found  that  the  abscess  does  not  heal.  Fistulous  openings 
continue  to  discharge  pus,  the  limb  remains  swollen  and  ten- 
der, and  it  is  liable  to  occasional  recurrences  of  inflammation, 
which  are  sometimes  almost  as  severe  as  the  original  attack, 
and  are  attended  by  the  formation  of  new  suppurative  tracks, 
which  at  new  points  communicate  with  the  cavity  of  the  in- 
volucrum.  On  examining  the  limb  at  this  time,  it  is  found 
that  the  swelling  and  induration  of  the  soft  parts  are  gradually 
disappearing,  while  a  deeper  and  firmer  enlargement  is  taking 
their  place,  which  is  manifestly  due  to  the  gradual  formation  of 
the  involucrum.  This  is  the  condition  of  the  limb  during  the 
process  of  sequestration. 

When  the  sequestrum  is  fully  detached,  and  after  the  in- 
volucrum is  completely  formed,  no  marked  change  takes  place 
in  the  symptoms.  The  abscesses  have  gradually  contracted 
down  to  fistulse,  the  orifices  of  which  present  a  few  large,  soft, 
pouting  granulations,  which  are  characteristic  of  the  presence 
of  a  foreign  body  at  the  bottom  of  the  fistula.  The  soft  parts 
have  resumed  their  natural  condition,  and  the  deep  involucral 
swelling  has  become  of  a  bony  hardness  and  almost  insensible 
to  pressure.  The  discharge  continues  constant,  but  usually 
small,  from  the  fistulous  tracks,  and  the  patient,  having  recov- 
ered his  general  health,  begins  to  use  the  limb  with  more  and 
more  freedom.  This  state  of  things  may  continue  indefinitely 
with  but  little  variation.  If  the  fistulse  show  a  disposition  to 
heal,  the  matter  accumulates  and  gives  rise  to  a  renewal  of 


NECROSIS.  141 

some  of  the  old  sufferings  until  it  again  finds  its  way  to  the 
surface.  As  a  rule,  the  fistulas  do  not  heal  even  for  a  short 
time,  and  I  believe  never  permanently,  while  the  sequestrum 
continues  unremoved. 

I  have  thus  presented  an  outline  of  the  ordinary  course  of 
one  of  the  most  characteristic  and  common  forms  of  necrosis. 
During  the  course  of  this  disease  the  patient  is  exposed  to  sev- 
eral sources  of  danger  which  are  worthy  of  being  separately 
noticed.  In  the  first  place,  when  the  death  of  bone  has  in- 
volved the  tissues  near  the  joints,  these  may  become  implicated 
directly  or  indirectly  in  the  consequences  of  the  disease.  It  is 
always  noticed  that,  when  the  sequestrum  is  near  the  joint, 
the  surrounding  inflammation  reaches  to  the  fibrous  structures 
of  the  joint,  which  gradually  grows  stiffer  and  stiffer,  until  the 
use  of  the  joint  is  seriously  impaired,  and  often  till  complete 
immobility  is  established.  This  is  particularly  marked  in  cases 
of  necrosis  of  the  lower  end  of  the  femur,  where  the  knee-joint 
is  apt  to  become  the  seat  of  a  false  anchylosis,  which  is  often 
complete  enough  to  entirely  abolish  its  movements.  This  is  a 
condition  which  is  a  necessary  consequence  of  the  proximity 
of  the  disease,  and  one  which  therefore  cannot  be  entirely  pre- 
vented. Something  may  be  done,  however,  by  encouraging 
the  patient  to  practise  the  movements  of  the  rigid  joint  sys- 
tematically and  regularly,  and  thus  in  some  degree  obviate  the 
increase  of  the  trouble.  But,  the  most  important  practical 
indication  to  be  deduced  from  this  well-known  tendency  to 
impairment  of  a  neighboring  joint  is,  to  remove  the  cause  of 
the  impairment  as  soon  as  possible,  by  getting  rid  of  the  se- 
questrum. If  for  no  other  reason  an  operation  is  required, 
this  is  always  a  good  one.  I  had  under  my  care,  a  few  years 
ago,  a  member  of  our  medical  class,  who  had  suffered  for  years 
with  necrosis  of  a  limited  extent  in  the  lower  end  of  his  femur. 
For  some  reason  he  had  not  been  advised  to  have  it  operated 
on,  and  he  had  submitted  to  its  annoyances,  and  had  attended 
lectures  regularly,  until  he  began  to  find  that  the  knee,  which 
had  long  been  getting  stiff,  was  fast  becoming  useless.  He 
then  consulted  me,  and  I  advised  an  operation,  which  was  per- 
formed, and  a  considerable  sequestrum,  of  the  compact  layer 
of  the  condyles  just  above  the  joint,  was  removed.  The  wound 


142  DISEASES  OF  BONE. 

healed  rapidly  and  perfectly,  but  the  stiffness  of  the  joint  was 
no  more  tractable  than  it  had  been  before.  Under  these  cir- 
cumstances, anxious  to  fill  a  hospital  appointment  which  his 
merit  had  secured  him,  and  ambitious  to  distinguish  himself  in 
his  profession,  he  begged  me  to  try  forced  flexion  of  the  joint. 
The  original  wound  made  in  the  operation  being  several  months 
healed,  and  there  being  no  evidence  of  any  disease  about  the 
joint,  I  thought  it  a  favorable  case  for  this  proceeding,  which 
I  accordingly  adopted.  Placing  him  under  ether,  and  having 
arranged  a  couch  with  reference  to  the  leverage  of  the  leg,  I 
made  the  most  powerful  efforts  to  break  up  the  adhesions,  but 
with  only  a  partial  success,  which,  though  it  procured  him  some 
increase  in  the  movement  of  the  joint,  did  not  satisfy  him.  At 
his  urgent  request,  and  sympathizing  with  his  brave  determi- 
nation to  fit  himself  for  life's  duties,  I  made,  a  few  weeks  after, 
another  attempt,  and,  being  better  prepared  with  my  mechani- 
cal arrangements,  and  perhaps  being  more  determined  to  suc- 
ceed, I  made  more  strenuous  efforts  to  move  the  obstinately- 
rigid  joint,  when  all  at  once,  while  I  was  trying  to  force  flexion 
as  far  as  I  could,  something  gave  way  with  a  snap,  and  the 
joint  yielded  in  the  most  satisfactory  manner.  I  was  shocked 
to  find,  however,  that  this  success  had  been  secured  at  the  ex- 
pense of  a  considerable  laceration  of  the  integuments  of  the 
anterior  aspect  of  the  joint  at  a  point  where  there  had  been 
some  cicatricial  adhesion  of  the  skin  to  the  bone,  from  long-past 
inflammation,  and  still  more  alarmed  to  find  that  this  lacera- 
tion, of  some  inch  and  a  half  long,  admitted  the  finger  into 
the  cavity  of  the  knee-joint.  I  instantly  closed  the  wound, 
and  placed  the  joint  at  perfect  rest,  and  had  the  good  fortune 
to  secure  immediate  union,  without  a  bad  symptom  on  the  part 
of  the  joint,  and  I  had  the  satisfaction  to  find  that  I  had  gained 
a  degree  of  flexion  which  was  amply  sufficient  for  the  ordinary 
use  of  the  limb,  and  which  he  not  only  retained,  but  by  perse- 
vering effort  considerably  improved  upon. 

Another  mode  in  which  the  joints  become  involved  by 
necrosis,  and  fortunately  a  rare  one,  is  by  death  of  cancellous 
tissue  reaching  to  the  articular  surface  itself.  When  this  oc- 
curs, there  is  sometimes  a  protective  inflammation  which  shuts 
off  the  general  cavity  of  the  joint  from  the  effects  of  the  sepa- 


NECROSIS.  1 43 

ration  of  and  suppuration  round  the  sequestrum,  and  the  dead 
piece  may  be  removed  without  really  opening  the  synovial  cav- 
ity ;  or  this  protective  inflammation  may  be  wanting,  or  of  an 
unhealthy  character,  allowing  contact  of  the  morbid  fluids  with 
the  synovial  cavity,  and  thus  producing  a  general  arthritis 
which  is  apt  to  be  destructive  in  its  tendencies,  the  more  so 
from  the  constant  presence  of  the  exciting  cause.  Of  this  we 
had  a  good  exemplification  in  a  syphilitic  patient  in  the  New 
York  Hospital,  who  had  been  long  suffering  from  disease  of 
the  lower  end  of  the  tibia,  embracing  the  internal  malleolus. 
This  falling  into  necrosis,  involved  the  joint  in  acute  attack  of 
inflammation,  which  soon  rendered  amputation  necessary.  The 
specimen,  when  macerated,  showed  a  considerable  disk  of  the 
cartilaginous  surface  forming  part  of  the  sequestrum,  which 
was  almost  ready  to  separate.  Similar  facts  have  been  re- 
ported in  many  instances ;  and  the  whole  subject  of  the  dan- 
ger to  joints  from  their  proximity  to  sequestra  is  most  impor- 
tant, as  suggesting  the  early  removal  of  the  dead  portion  of 
bone,  before  the  evils  apprehended  have  had  time  to  occur. 

A  second  danger  in  necrosis  is  haemorrhage.  We  have 
seen  that  the  sequestrum  when  separated  has  a  tendency  to 
work  its  way  toward  the  surface,  and  that,  when  it  is  not  re- 
sisted by  the  imprisoning  involucrum,  a  large  sequestrum  will 
sometimes  be  thus  extruded.  In  working  its  way  thus  among 
the  tissues,  it  is  liable  to  encounter  some  artery  of  importance 
which  may  be  eroded  by  its  pressure.  In  vessels  of  moderate 
size,  and  sometimes,  doubtless,  in  the  main  trunks  themselves, 
Nature  institutes  a  protective  process  against  such  erosion,  and 
the  vessel  is  closed  by  fibrine  before  its  coats  are  perforated,  and 
haemorrhage  is  thereby  prevented.  Unfortunately,  however,  it 
does  sometimes  happen  either  that  the  protective  action  is  im- 
perfect, or  that  the  destructive  effect  of  the  sharp  edge  of  the 
bone  is  too  sudden  and  rapid  for  the  calibre  of  the  vessel  to  be 
entirely  sealed,  and  haemorrhage  takes  place.  This  accident, 
as  far  as  I  have  observed  it,  always  takes  place  in  the  largest 
trunks,  small  vessels  being  so  much  more  likely  to  be  safely 
plugged  than  large  ones,  and  this  pathological  fact  has,  I  think, 
great  practical  significance ;  for,  if  we  can  confidently  pro- 
nounce that  the  haemorrhage,  in  a  given  case  of  necrosis,  has 


144  DISEASES  OF  BONE. 

its  source  in  the  erosion  of  a  large  trunK,  ana  not  of  a  small 
branch,  it  is  evident  that  the  case  from  that  fact  assumes  an 
importance  which  is  immediate  and  pressing.  And  it  is  the 
more  necessary  that  this  should  be  fully  appreciated,  because 
these  haemorrhages  are  sometimes  exceedingly  deceptive  in 
their  behavior,  and  some  of  those  which  first  occur,  even  from 
the  largest  trunks,  are  quite  trivial  in  amount,  and  are  easily 
checked,  or  stop  spontaneously.  This  is  extremely  apt  to  de- 
ceive the  surgeon  into  the  belief  that  the  bleeding  vessel  is  not 
large,  and  that  the  danger  is  not  great.  It  may  be  a  fatal 
mistake. 

We  have,  in  the  college  museum,  a  beautiful  preparation 
taken  from  a  medical  gentleman  of  this  city,  who  had  been 
suffering  from  necrosis  of  the  femur  for  many  years.  On  a 
sudden,  without  assignable  cause,  he  was  attacked  with  haem- 
orrhage, the  blood  flowing  quite  freely  for  a  time  from  the  fis- 
tulous  openings,  and  then  ceasing  of  its  own  accord.  Once  or 
twice  bleeding  recurred,  always  stopping  in  a  short  time  spon- 
taneously, but  nevertheless  reducing  him  considerably  by  the 
whole  amount  of  blood  lost.  Finding  the  bleeding  so  moderate 
and  so  controllable,  neither  he  nor  his  medical  advisers  took 
serious  alarm  until  a  day  or  two  after,  when  a  rapid  and  pro- 
fuse haemorrhage  brought  him  almost  to  death's  door.  In  this 
unpromising  state  amputation  was  performed,  but  too  late  to 
save  the  unfortunate  gentleman  from  a  death  clearly  due  to  a 
non-appreciation  of  the  pathological  condition  which  the  speci- 
men most  sadly  illustrates.  It  shows  a  large,  sharp-edged  se- 
questrum, which,  having  partially  emerged  from  its  bed,  had 
worked  its  way  down  toward  the  popliteal  space,  and  there, 
by  erosion,  opened  the  popliteal  artery.  By  contrast,  another 
case  occurred  to  my  colleague,  Dr.  Gurdon  Buck,  who  had 
under  his  care  a  boy  of  about  twelve  or  fourteen  years  of  age, 
with  a  very  extensive  necrosis  of  the  femur.  As  it  was  during 
the  hot  season,  and,  as  the  patient  wras  much  reduced  by  his 
disease,  an  operation  was  postponed,  and  the  boy  was  allowed 
to  go  about,  hoping  that  his  health  would  improve  as  the  cooler 
season  arrived.  In  fact,  he  was  improving  very  greatly,  when, 
after  a  moderate  walk,  he  found  his  pantaloons  and  shoe  of  the 
diseased  side  filled  with  blood.  This  bleeding  stopped  of  itself, 


NECROSIS.  145 

but,  from  its  extent  and  rapidity,  Dr.  Buck  believed  it  to  be 
from  a  main  trunk,  and  stood  ready  on  the  occasion  of  its  re- 
currence, which  soon  took  place,  to  amputate  the  limb,  which 
he  did  quite  high  up,  and  the  boy's  life  was  saved.  Dissection 
showed  that  the  upper  sharp  point  of  the  sequestrum  had 
opened  the  femoral  artery  not  far  from  the  origin  of  the  pro- 
funda.  This  specimen  is  preserved  in  the  New  York  Hospital 
Museum. 

I  have  examined  carefully,  during  the  last  twenty  years, 
thirteen  cases  of  necrosis  in  which  haemorrhage  occurred  of 
sufficient  severity  to  require  surgical  interference.  In  every 
one  of  these  it  was  the  main  artery  of  the  region  which  was 
the  source  of  the  haemorrhage,  except  in  one  case,  and  then  it 
was  the  vertebral  which  had  been  eroded  by  a  fragment  of 
dead  bone,  from  a  pistol-wound,  which  was  in  a  favorable  state 
of  healing  when  the  fatal  haemorrhage  occurred.  In  each  case 
the  coats  of  the  artery  were  eroded  evidently  by  the  direct 
contact  of  a  sharp  edge  of  the  sequestrum,  with  one  exception, 
and  then,  though  the  main  artery  was  opened,  and  a  sharp 
sequestrum  was  quite  near,  we  could  not  pronounce  positively 
that  the  hole  observed  in  the  side  of  the  artery  was  actually  due 
to  the  pressure  of  the  sharp  edge  of  bone.  The  number  of 
observations  is  too  small  to  decide  the  point  that  small  vessels 
never  bleed  from  the  cause  we  are  studying;  but  the  testimony 
of  these  few  is  so  nearly  uniform  that  I  think  it  may  safely  be 
accepted  as  a  pathological  law,  and  I  am  quite  sure  it  affords 
our  soundest  practical  indication.  Precisely  what  that  indica- 
tion is,  must  be  settled  by  the  features  presented  by  each  case ; 
but  it  is  hardly  necessary  to  say  that  the  remedy  does  not  con- 
sist in  the  mere  removal  of  the  cause  of  the  mischief,  that  is, 
the  sharp  edge  of  the  dead  bone.  "When  that  is  removed, 
there  remains  the  opened  artery  to  be  cared  for,  and,  if  my 
position  is  correct,  that  this  opened  artery  is  a  main  trunk,  very 
little  hope  can  be  entertained  that  ISTature  will  be  able  to  close 
the  wounded  vessel  without  assistance  from  art. 

Two  courses  present  themselves  to  the  surgeon  in  this  seri- 
ous emergency :  The  first  is,  to  make  an  attempt  to  reach  and 
tie  the  wounded  vessel ;  and  the  second  is,  to  amputate  if  the 
ligature  cannot  safely  or  successfully  be  undertaken.  The 
10 


146  DISEASES  OF  BONE. 

point  of  urgent  importance,  however,  is,  in  my  judgment,  not 
to  delay  till  a  sudden  gush  of  blood  places  your  patient  be- 
yond the  hope  of  benefit  from  any  operation,  be  it  ever  so 
clearly  indicated,  or  ever  so  skilfully  performed. 

The  two  following  cases,  which  have  recently  come  under 
my  observation,  illustrate  extremely  well  the  points  of  practice 
I  have  here  dwelt  upon  : 

Martin  Clancy,  aged  twenty-four,  an  oysterman,  was  admit- 
ted into  Bellevue  Hospital,  October  29, 1869.  He  was  extremely 
feeble  and  exsanguine,  and  stated  that  he  had  been  bleeding 
for  five  days  from  an  ulcer  in  his  thigh.  This  bleeding  had 
occurred  suddenly,  without  obvious  cause,  and  had  stopped 
spontaneously  for  a  time.  It  had  recurred  several  times  in 
the  same  unprovoked  manner;  and  by  the  frequency  of  these 
bleedings,  some  of  them  very  large,  he  had  been  reduced  to 
his  present  alarming  condition.  He  had  worn  a  tourniquet 
for  many  hours  before  his  arrival  at  the  hospital,  put  on  by  his 
surgical  attendant  out-of-doors.  It  was  clear,  from  the  exami- 
nation of  his  case,  and  from  its  previous  history,  that  he  had 
had  necrosis  of  the  lower  part  of  the  femur,  dating  back  seven 
years,  and  several  openings  existed  in  the  popliteal  region, 
from  which  the  blood  had  issued.  The  probe  detected  a  large 
sequestrum,  lying  loose  and  quite  superficial ;  and  the  question 
in  consultation  was,  "What  was  the  vessel  opened  ?  From  the 
amount  of  blood  lost,  from  the  spontaneous  character  of  the 
bleedings,  and  their  persistent  recurrence,  and  from  the  situa- 
tion of  the  sequestrum,  we  had  no  hesitation  in  deciding  that 
it  was  the  popliteal  trunk  that  was  injured,  and  in  determining 
to  cut  down  and  remove  the  sequestrum,  and,  if  possible, 
apply  a  ligature  to  the  artery.  The  operation  was  performed 
by  Dr.  A.  'B.  Mott,  and  was  truly  a  difficult  and  delicate  one. 
An  incision,  seven  inches  long,  was  made  over  the  course  of 
the  artery,  embracing  as  many  of  the  fistulous  orifices  as  pos- 
sible, and  soon  a  large  cavity  was  exposed,  occupying  most  of 
the  popliteal  space  above  the  knee,  in  which  lay  loose  a  large, 
flat,  sharp-edged  sequestrum,  evidently  formed  by  the  death 
of  the  compact  layer  of  the  posterior  surface  of  the  femur,  just 
above  the  condyles.  This  removed,  left  a  bed  of  granulations, 
in  which  it  had  rested ;  but  no  haemorrhage  could,  at  the  mo- 


NECROSIS.  147 

ment,  be  induced,  by  which  a  clew  to  the  injured  artery  might 
be  gained.  The  operator  was  obliged,  therefore,  by  a  most 
tedious  and  cautious  dissection,  among  parts  consolidated  by 
long-continued  inflammation,  to  search  for  the  artery,  guided 
by  a  pulsation,  which,  in  this  indurated  condition  of  parts,  and 
in  the  feeble  state  of  the  circulation,  was  of  very  little  assist- 
ance. After  a  long  search  at  the  upper  part  of  the  cavity,  the 
artery  was  exposed,  and  carefully  traced  downward,  until  we 
arrived  at  a  ragged  opening  on  its  side,  from  which,  on  loosen- 
ing the  tourniquet,  the  blood  now  spurted  freely.  A  ligature 
was  applied  above  and  below  the  opening,  the  two  ligatures 
being  about  an  inch  apart.  The  wound  was  only  partly  closed, 
leaving  its  central  portion  open,  and  was  dressed  lightly.  Ev- 
ery thing  went  on  favorably.  No  haemorrhage  occurred,  and 
the  man  gained  rapidly  in  appearance  and  in  strength.  The 
wound  granulated  well,  and  filled  up  so  rapidly,  that,  by  the 
19th  of  December,  it  was  almost  healed,  and  on  the  31st  he 
was  discharged  from  the  hospital.  He  could  then,  about  nine 
weeks  after  the  operation,  walk  quite  well,  though  he  could 
not  flex  the  foot.  No  pulsation  in  anterior  or  posterior  tibials. 
His  health  seemed  to  be  perfectly  reestablished. 

The  second  case  was  not  so  fortunate  in  its  results,  and  is  a 
noteworthy  illustration  of  the  formidable  nature  of  the  accident 
we  are  studying,  because  the  gravity  of  the  situation  was  fully 
appreciated  from  the  moment  the  accident  occurred,  and  every 
thing  that  science  and  skill  could  do  was  done,  and  done 
promptly,  without  achieving  the  saving  of  the  patient's  life. 
The  case  occurred  in  the  practice  of  my  friend  Dr.  George  A. 
Peters,  of  this  city,  and  by  his  kindness  I  had  the  opportunity 
to  study  the  specimens  in  their  recent  state.  The  patient  was 
a  gentleman  about  forty-five  years  of  age,  of  ordinarily  good 
health  and  active  habits.  He  had  had  several  attacks  of  in- 
flammation about  his  knee,  the  earliest  one  occurring  in  child- 
hood ;  and  on  one  occasion  he  had  had  a  slight  exfoliation  of 
bone  from  the  lower  part  of  the  femur.  He  had  of  late  years 
entirely  recovered  from  the  effects  of  these  attacks ;  and,  with 
the  exception  of  a  slight  stiffness  and  lameness  of  the  joint,  he 
considered  himself  a  well  man.  Dr.  Peters  was  summoned  to 
him  at  his  residence,  out  of  town,  one  Sunday  morning  in  Sep- 


148  DISEASES    OF  BONE. 

tember,  1869,  and  found  that  he  had  had  that  morning,  while 
making  some  slight  movement  in  bed,  a  severe  haemorrhage, 
which  had  reduced  him  to  an  alarming  point  of  prostration. 
The  history  given  was,  that  about  two  months  previously,  an 
inflammation  had  declared  itself  in  the  old  seat  of  disease  in 
the  ham,  and  had  gone  on  slowly  to  suppuration,  and  had  been 
opened  by  his  attending  surgeon  in  two  places.  The  inflam- 
mation subsided  somewhat,  but  the  abscess  did  not  heal ;  and, 
though  he  was  able  to  keep  about  his  business,  he  suffered 
more  or  less  constant  inconvenience  from  his  disease.  He  had 
only  been  confined  to  the  house  a  few  days ;  and,  beyond  a 
slight  increase  in  local  suffering,  no  new  features  had  devel- 
oped themselves  when  the  haemorrhage  took  place,  as  above 
stated. 

The  bleeding  had  been  so  severe,  that,  although  no  recur- 
rence had  taken  place,  his  alarming  condition  warranted  the 
most  extreme  measures  to  prevent  a  renewal  of  it.  The  wound 
was  therefore  opened  freely,  and  a  large  cavity  exposed,  occu- 
pying the  popliteal  space,  the  bottom  of  which  cavity  was  the 
posterior  surface  of  the  lower  end  of  the  femur,  in  a  condition 
of  extensive  disease,  with  a  bare  and  very  rough  surface  ex- 
tending several  inches  up  the  bone  and  downward,  so  as  to 
involve  the  knee-joint,  into  which,  through  the  ulcerated  liga- 
mentum  "Winslowi,  the  finger  could  easily  be  passed.  A  small, 
thin,  and  very  sharp  detached  fragment  of  bone  lay  loose  in 
the  cavity.  The  condition  of  extensive  disease  of  the  femur, 
the  opened  knee-joint,  with  the  almost  certainty  of  the  poplit- 
eal artery  being  eroded,  seemed  to  justify  and  to  demand  am- 
putation of  the  limb,  which  was  performed  without  delay, 
almost  without  loss  of  blood.  So  great  was  the  depression  of 
the  system,  that  no  proper  reaction  took  place,  and  he  died 
during  the  night  following  the  operation. 

On  examination  immediately  after  the  operation,  the 
large  cavity,  mentioned  as  occupying  the  popliteal  space,  was 
found  to  extend  far  round  the  femur  on  each  side;  and  into  it, 
therefore,  the  whole  posterior  and  lateral  surfaces  of  the  end 
of  the  femur  formed  a  sort  of  projection.  All  the  bone-surface 
thus  exposed  was  bare,  rough,  irregularly  eroded,  presenting 
only  here  and  there  a  granulating  surface.  The  knee-joint  was 


NECROSIS. 


149 


filled  with  pus,  and  rapidly  disorganizing.  The  popliteal  ar- 
tery ran  along  the  superficial  wall  of  this  cavity,  but  very 
close  to  the  exposed  bone-surface,  and,  at  about  the  centre  of 
the  popliteal  space,  was  opened  by  a  clean  oblique  cut,  just 
such  as  is  usually  made  in  the  operation  of  venesection.  'No 
other  detached  sequestrum  was  found.  After  maceration,  the 
end  of  the  femur  was  found  to  be  light,  porous,  and  spongy ; 
the  medullary  cavity  very  large,  and  the  cancellous  tissue  very 
open.  Both  the  posterior  and  lateral,  and  some  of  the  anterior 
surfaces  of  the  bone,  were  irregularly  eroded,  the  posterior 
much  the  more  deeply.  Almost  all  the  compact  portion  of 


Fio.  22.— (From  N.  T.  Hospital  Museum.) 


FIG.  23.— (From  N.  T.  Hospital  Museum.) 


the  shaft,  where  it  is  not  destroyed  by  erosion,  has  become 
porous  as  well  as  thin.  At  several  points,  where  this  compact 
lamina  still  remains  undestroyed,  a  dull,  white,  opaque  appear- 
ance of  the  surface  indicates  that  it  has  suffered  necrosis. 
Such  a  necrosed  plate,  separating  from  the  posterior  surface, 
was  undoubtedly  the  cause  of  the  wound  in  the  artery.  The 


150  DISEASES  OF  BOXE. 

same  necrosed  appearance  penetrated  at  points  into  the  sub- 
stance of  the  cancellous  tissue,  which  had  evidently  been  ex- 
tensively infiltrated  with  pus.  In  some  points  small  cavities 
existed,  which  doubtless  had  contained  pus,  and  which  did  not 
communicate  with  the  surface.  No  loose  sequestra  were  to  be 
found.  At  the  point  of  amputation  the  bone  has  become 
harder  than  natural,  with  some  small  exostotic  growths  on  the 
outskirts  of  the  inflamed  region. 

That  the  danger  from  haemorrhage  in  necrosis  is  a  real  and 
a  formidable  one,  even  in  circumstances  most  favorable  for 
prompt  surgical  assistance,  will  perhaps  more  clearly  appear 
from  the  statement  that,  of  eleven  cases  which  I  have  met 
with,  mostly  occurring  in  the  New  York  Hospital,  six  have 
died.  In  ten  of  these  every  thing  was  promising  well  when 
the  haemorrhage  occurred ;  and  in  every  case  but  that  of  the 
vertebral  the  injured  vessel  was  accessible  to  ligature,  or  the 
limb  might  have  been  removed  by  amputation.  These  things 
taken  into  consideration,  my  recommendation  of  promptness 
in  operation  receives  an  emphatic  indorsement.  Delay  in 
hope  of  saving  the  limb  is  fatal  to  life. 

Fig.  23  represents  the  lower  end  of  a  femur  where  amputa- 
tion was  performed  for  haemorrhage  from  the  popliteal  artery, 
which  had  been  opened  by  a  sharp  sequestrum  detached  from 
the  posterior  surface  of  the  femur.  The  specimen  is  curious 
from  the  peculiar  manner  in  which  the  bone  is  perforated  by 
the  actions  going  on  round  the  bed  from  which  the  sequestrum 
came.  It  is  in  the  New  York  Hospital  Museum. 

The  last  danger  to  which  I  shall  allude  is  exhaustion.  In 
a  feeble  subject,  with  extensive  necrosis,  we  sometimes  have 
thrown  upon  the  powers  of  Nature  more  than  they  can  bear. 
The  reparative  actions,  which  should  be  promptly  and  health- 
fully excited  as  soon  as  the  inflammatory  stage  is  passed,  are 
replaced  by  the  continuance  of  inflammation  in  a  subacute 
form,  accompanied  with  a  profuse  secretion  of  pus.  No  proper 
involucruni  is  formed.  The  tissues  are  largely  infiltrated  with 
inflammatory  products.  The  tenderness  and  pain  do  not  dis- 
appear. The  line  of  separation  forms  slowly  and  imperfectly. 
In  short,  the  whole  process  is  a  morbid  instead  of  a  healthy 
one ;  and  the  patient's  condition  corresponds,  in  an  excited, 


NECROSIS.  151 

irritable  pulse,  irregular  hectic  fever,  want  of  appetite,  ema- 
ciation, and  all  those  numerous  evidences  that  inflammation 
rather  than  reparation  is  going  on  about  the  seat  of  disease. 
Here,  every  thing  depends  upon  the  surroundings  of  the 
patient,  and  the  assiduity  with  which  wholesome  and  proper 
regimen  is  brought  to  bear  upon  the  overtaxed  powers.  The 
best  of  air,  the  best  of  food,  tonics,  invigorants,  stimulants,  will, 
happily,  in  most  cases,  carry  the  patient  through  the  period  of 
danger ;  but,  if  the  condition  do  not  soon  improve,  if  the  ex- 
haustion be  gaining  upon  you  rather  than  yielding  to  your 
efforts,  remember  that  this  very  condition  is  reacting  upon  the 
local  state,  and  making  bad  conditions  daily  worse,  and  it  is 
well  to  be  very  circumspect  lest,  in  the  anxiety  to  save  a  limb, 
you  sacrifice  a  life.  This  form  of  danger  from  exhaustion  be- 
longs to  the  early  stages  of  the  disease,  and  depends  very  much 
upon  original  weakness  of  constitution.  When  once  an  involu- 
crum  has  formed,  and  the  patient  has  recovered  a  partial  use  of 
his  limb,  the  danger  of  exhaustion  from  continued  drain  by  the 
suppuration,  in  my  own  observation,  is  confined  to  those  in 
whom  some  other  accidental  complications  have  conspired  with 
the  original  disease  to  depress  the  vital  powers,  and  in  such 
cases  the  source  of  danger  belongs  more  to  the  complication 
than  to  the  primary  disorder. 

Having  thus  passed  in  review  the  principal  features  of  a 
case  of  necrosis  which  has  been  selected  as  a  type  of  the  dis- 
ease, we  must  now  look  at  some  classes  of  cases  in  which  im- 
portant deviations  from  this  standard  course  present  them- 
selves. Among  these  varieties  of  necrosis  entitled  to  special 
study  we  have — 1.  Superficial  necrosis  or  exfoliation.  2.  In 
heads  of  bones  near  joints.  3.  In  cranial  bones.  4.  In  jaw- 
bones. 5.  After  fractures.  6.  After  amputations.  T.  With- 
out suppuration.  8.  Without  exfoliation. 

1.  Superficial  Necrosis,  or  Exfoliation. — This  simplest  and 
most  common  form  of  necrosis  differs  from  that  we  have  been 
studying,  mainly  in  the  fact  that  we  trace  little  or  no  evidence 
of  any  reparative  or  compensatory  process  when  the  separa- 
tion ia  taking  or  has  taken  place.  Hence  we  have  no  involu- 
crum  enclosing  the  sequestrum,  which  usually  lies  exposed  in 


152  DISEASES  OF  BONE. 

the  cavity  of  the  suppurating  soft  parts.  The  granulations 
which  form  its  bed,  after  separation  is  complete,  push  it  with- 
out difficulty  toward  the  surface,  where  it  either  makes  its  way 
out  with  the  discharge,  if  it  be  small,  or,  if  it  be  large,  presents 
itself  at  the  opening  of  one  of  the  fistulse,  whence  it  can  easily 
be  removed  by  the  surgeon.  In  this  way  a  large  number  of 
slight  necroses,  produced  by  detachments  of  periosteum,  or  after 
fractures,  or  after  operations  on  bones,  pass  through  their  va- 
rious stages  so  easily  and  with  so  little  disturbance,  as  scarcely 
to  constitute  a  complication  of  the  wound,  or  materially  to  re- 
tard its  healing.  There  are  certain  cases,  however,  where  this 
superficial  necrosis  becomes  formidable  from  its  shape  and  ex- 
tent. It  sometimes  happens  that  a  considerable  portion  of  the 
surface  of  the  bone  undergoes  necrosis,  so  that  the  shaft  of  a 
long  bone  may  present  on  all  sides,  and  in  the  greater  portion 
of  its  length  a  necrosis,  which  is  entirely  superficial,  affecting 
only  the  outer  compact  layer.  As  a  spontaneous  disease  this 
occurs  most  often  in  children,  in  whom  some  sudden  inflamma- 
tion of  the  periosteum  has  produced  the  disease,  without  the 
bone  itself  being  seriously  implicated.  This  was  well  illus- 
trated in  the  case  of  a  little  boy  who  recently  died  in  the  New 
York  Hospital.  He  was  received  in  consequence  of  injuries 
from  the  passage  of  a  rail-car  over  his  right  foot.  About  a 
week  after,  he  began  to  complain  of  pain  in  his  left  tibia,  which 
was  not  known  to  be  injured.  This  was  the  19th  of  July. 
Soon  phlegmonous  inflammation  developed  itself,  occupying 
the  whole  leg,  and  extending  above  the  knee  and  below  the 
ankle.  August  VZth. — The  abscess  was  opened,  giving  issue 
to  a  very  large  amount  of  pus.  The  matter  found  vent  at 
several  points,  and  it  soon  became  evident  that  the  tibia  was 
extensively  diseased.  The  probe  found  dead  bone  at  all  points, 
the  integuments  were  undermined,  the  discharge  fetid,  and  the 
little  fellow  suffered  greatly.  He  was  rapidly  sinking  from  his 
disorder,  when  amputation  was  proposed  to  save  his  life.  It 
was  refused  by  his  friends,  and  he  was  soon  reduced  to  a  mere 
skeleton  by  his  sufferings  and  the  immense  discharge  from  the 
cavities.  He  lingered  until  the  20th  of  September,  when  he 
died.  The  whole  tibia  was  found  to  be  diseased.  The  exter- 
nal compact  shell  had  died  almost  in  its  whole  extent,  and  at 


NECROSIS.  153 

one  or  two  points  a  partial  exfoliation  had  commenced.  With- 
in this  outer  dead  shell  the  bone-tissue  was  in  a  state  of  in- 
flammation. It  was  congested  with  blood,  softer  than  natural, 
extensively  eroded  on  its  epiphyseal  extremities,  and  from 
several  points  exuberant  growth  of  layers  of  new  bone,  still 
soft,  showed  an  attempt  on  the  part  of  Nature  to  form  an  in- 
volucrum.  So  soft  was  the  bone-tissue  of  the  head  of  the 
tibia  that  it  broke  off  in  removing  it,  and  could  be  crushed  by 
the  fingers.  The  sequestrum,  if  removed,  would  have  formed 
a  thin  tube,  representing  all  the  external  layer  of  the  shaft  of 
the  tibia. 

2.  Necrosis  occurring  in  Heads  of  Bones  near  Joints. — 
Here  the  significant  feature  is,  the  relation  of  the  disease  to 
the  articular  cavity.  The  sequestrum  may  either  extend  into 
the  joint,  or  it  may  lie  near  it  without  involving  the  articular 
lamella.  In  the  first  case,  the  danger  of  destructive  inflam- 
mation of  the  joint  is  very  great,  and  in  many  instances,  I 
think,  I  have  seen  evidence  that  the  presence  of  a  small  se- 
questrum has  been  the  cause  of  an  unfortunate  termination  of 
a  joint  disease,  which  in  other  respects  might  have  had  a 
favorable  issue.  This  is  the  result  usually  to  be  anticipated 
where  the  sequestrum  reaches  actually  into  the  joint,  but  I 
have  seen  more  than  one  instance  where  this  condition  ob- 
tained, and  where,  nevertheless,  the  integrity  of  the  joint  was 
not  compromised.  Thus,  I  had  a  young  man  under  my  care 
who  had,  over  the  external  malleolus,  a  foul  and  ill-behaving 
ulcer,  which  was  probably  syphilitic  in  its  origin.  It  had  ex- 
isted for  many  months,  and,  when  I  saw  it,  had  exposed  a  con- 
siderable portion  of  the  external  malleolus,  which,  dead  and 
dry,  formed  the  bottom  of  the  ulcer.  Seeing  that  in  all  prob- 
ability the  sequestrum  involved  or  would  involve  the  articular 
surface,  I  feared  the  consequences  to  the  joint  when  the  separa- 
tion should  occur.  His  general  condition  was  strengthened  by 
appropriate  treatment ;  the  character  of  the  sore  improved,  and 
very  soon  the  dead  piece  became  movable.  It  was  not  dis- 
turbed until  it  had  become  very  loose,  and  then,  being  removed, 
we  were  agreeably  surprised  to  find  that  no  inflammation  oc- 
curred in  the  ankle-joint,  though  the  separated  piece  showed  a 
considerable  portion  of  the  articular  surface,  which  had  been 


154  DISEASES  OF  BOXE. 

applied  against  the  outer  surface  of  the  astragalus.  TVe  kept 
the  joint  very  still  for  a  while,  until  granulation  was  well  ad- 
vanced, and  then  carefully  allowed  a  little  movement.  It  was 
well  borne,  and  gradually  increased,  until  a  very  satisfactory 
amount  of  motion  was  gained,  the  joint  all  the  time  remaining 
free  from  any  indication  of  inflammation.  The  only  explana- 
tion of  this  interesting  fact  is,  that  surrounding  adhesive  in- 
flammation had  closed  off  the  general  cavity  of  the  joint  from 
the  actions  which  were  going  on  round  the  dead  bone, 
which  was  thus  placed  practically  external  to  a  joint  of  which 
really  it  formed  a  part.  This  fortunate  termination  must  be 
rare.  Its  occasional  occurrence  should  give  us  encouragement, 
and  keep  us  from  despairing  in  similar  apparently  hopeless 
cases. 

A  much  more  frequent  case  is  that  in  which  the  sequestrum 
does  not  reach  to  the  joint-surfaces  of  the  bone  in  which  it  is 
situated,  but,  lying  very  near  these  joint-surfaces,  involves  them 
in  the  inflammatory  actions  of  which  it  is  the  centre  and  the 
cause.  Of  this,  Mr.  Stanley  gives  an  interesting  example  in 
the  case  of  a  young  girl  of  sixteen,  who  was  attacked  by  an 
inflammation  of  the  head  of  the  tibia,  which  was  followed  by 
necrosis.  Successive  attacks  of  inflammation  of  the  joint  oc- 
curred at  intervals  during  sixteen  years.  These  attacks  tinally 
grew  more  and  more- threatening,  until  the  knee-joint  became  so 
seriously  involved  as  to  render  amputation  necessary.  On  ex- 
amining the  limb,  there  was  found  "  a  dead  portion  of  the  can- 
cellous  tissue,  about  the  size  of  a  hazel-nut,  firmly  impacted 
in  the  interior  of  the  head  of  the  tibia,  half  an  inch  below  its 
upper  articular  surface.  .  .  .  The  several  structures  of  the  joint 
had  undergone  the  usual  changes  consequent  on  long-continued 
inflammation ;  the  synovia!  membrane  was  thick  and  pulpy, 
with  lymph  adhering  to  its  free  surface  ;  the  crucial  ligaments 
were  softened,  and  the  articular  cartilages  were  in  part  ab- 
sorbed." But,  besides  these  more  rare  cases  where  destructive 
disease  of  the  joint  is  produced  by  the  proximity  of  a  seques- 
trum, there  are  a  large  number  in  which,  by  a  slower  process, 
a  stiffness  of  the  neighboring  joint  is  produced,  which  very 
soon  amounts,  if  the  condition  be  not  obviated,  to  an  anchylo- 
sis. This  is  one  of  the  serious  consequences  of  necrosis,  and 


NECROSIS.  155 

unfortunately  it  is  one  which  does  not  cease  when  the  necrosis 
is  cured  ;  for,  by  the  long  continuance  of  the  anchylosis,  and 
the  consequent  disuse  of  the  joint,  its  constituent  parts  have 
become  so  adherent  to  one  another  by  organized  fibrine,  and  so 
changed  from  disuse,  that  but  little  can  be  done  to  restore  its 
usefulness.  It  should  be  borne  in  mind  that  this  implication 
of  the  neighboring  joint  may  occur  in  cases  where  the  necrosis 
is  not  in  the  immediate  proximity  of  the  joint,  but  at  some  lit- 
tle distance  from.  it.  I  have  now  under  my  care  a  young  gen- 
tleman in  whom  necrosis  of  the  femur  took  place  about  three 
years  ago.  I  recently  removed  the  sequestrum,  which  occu- 
pied a  very  large  share  of  the  shaft  of  the  femur,  but  did  not 
approach  within  perhaps  an  inch  of  the  knee-joint,  and  yet 
the  knee  is  hopelessly  anchylosed,  and  has  been  so  for  many 
months.  I  think  I  have  more  frequently  observed  this  condi- 
tion in  the  knee-joint  than  in  any  other,  and  more  frequently 
as  a  consequence  of  necrosis  of  the  lower  part  of  the  femur 
than  of  the  upper  part  of  the  tibia.  This  tendency  to  the 
implication  of  neighboring  joints  seems  to  me  to  offer  some 
practical  suggestions  in  the  management  of  the  disease :  1. 
Where  we  believe  the  necrosis  not  to  invade  the  joint-structures 
themselves,  but  merely  to  affect  them  by  proximity,  cannot 
something  be  done  to  obviate  the  consequences  of  these  succes- 
sive attacks  of  inflammation,  by  rigorously  insisting  on  prop- 
erly-conducted passive  motion,  after  each  attack  subsides,  and 
by  courageously  keeping  up  such  attention  to  the  motions  of 
the  joint  as  shall  prevent  or  diminish  its  tendency  to  hopeless 
rigidity  ?  2.  Let  no  time  be  lost  in  performing  the  operation 
and  removing  the  sequestrum.  Every  day's  delay  increases 
the  risk  of  inflammation  of  the  neighboring  joint,  ami  adds  to 
the  rigidity  which  is  rapidly  making  it  useless. 

In  connection  with  these  cases,  I  may  here  allude  to  the 
fact  that  the  cancellous  tissue,  in  some  of  the  short  bones,  as 
in  those  of  the  tarsus,  is  sometimes  the  seat  of  necrosis,  pre- 
senting features  somewhat  peculiar  to  its  situation. 

I  had,  in  Bellevue  Hospital,  a  carman,  aged  thirty-one,  in 
January,  1868,  who  presented  a  diseased  condition  of  the  os  cal- 
cis,  which  at  first  puzzled  me.  Ten  years  ago,  he  had  injured 
the  foot  by  striking  on  the  heel  in  jumping  from  a  height.  In- 


156  DISEASES  OF  BONE. 

flammation  followed  of  the  whole  region  of  the  heel,  which, 
after  several  weeks,  terminated  in  the  opening  of  an  abscess, 
and  the  discharge  of  matter  from  the  inside  of  the  heel.  About 
a  month  afterward,  a  similar  opening  took  place  on  the  outside. 
The  inflammation  subsided,  but  the  openings  had  never  healed. 
He  had  been  able,  most  of  the  time,  to  use  the  foot  without 
much  inconvenience.  I  examined  the  foot  carefully,  on  the 
19th  of  February.  There  was  some  enlargement  and  thicken- 
ing of  the  whole  calcaneal  region,  and  the  two  original  open- 
ings remained  nearly  opposite  one  another,  and  communicat- 
ing, so  that  a  probe  could  be  passed  through  the  bone,  from 
one  to  the  other.  The  probe  distinctly  touched  dead  bone. 
A  surgeon,  who  had  seen  him  some  weeks  previously,  had 
passed  a  seton  through  the  bone,  and  left  it  there.  It  had 
excited  but  little  action  of  any  kind.  The  history  led  me  to 
suspect  that  it  was  a  case  of  central  necrosis.  I  proceeded, 
therefore,  to  expose  the  outer  surface  of  the  os  calcis,  and  care- 
fully enlarged  the  opening  which  led  into  the  substance  of  the 
bone.  As  soon  as  it  was  large  enough  to  admit  my  little  fin- 
ger, I  discovered  a  loose  sequestrum,  which,  as  cautiously  as 
possible,  I  extracted,  not  without  breaking  off  some  of  its 
prominent  points.  It  was  of  the  size  and  somewhat  the  shape 
of  a  small  nutmeg,  and  was  composed  of  the  cancellous  tex- 
ture of  the  bone.  It  was  shrivelled  and  apparently  partly  de- 
composed, by  long  exposure  to  the  air  and  to  the  foul  secretions 
of  the  part.  After  removing  the  sequestrum,  the  finger  could 
be  introduced  into  a  cavity,  the  walls  of  which  were  covered 
with  thick,  firm,  and  apparently  healthy  granulations.  The 
patient  made  a  very  good  recovery.  One  other  case,  almost 
identical  in  its  features,  has  occurred  to  me,  in  a  lad  of  fifteen, 
in  whom  a  similar  operation  was  followed  by  a  like  satisfactory 
result. 

Again,  it  happens,  but  I  suspect  very  rarely,  that  the  whole 
bone  dies,  and  remains  enclosed  in  the  bag  formed  by  the  peri- 
osteum. This  condition  presented  itself  in  a  son  of  the  Rev. 
Mr.  P.,  whom  I  saw  in  consultation  with  Dr.  J.  L.  Little,  in 
January,  1868.  About  five  weeks  previously  he  had  noticed, 
about  the  insertion  of  the  tendo  Achillis,  a  swelling  which  had 
come  on  gradually,  and  which  he  attributed  to  a  twist  of  the 


NECROSIS.  157 

ankle  received  some  time  before.  This  swelling  inflamed  and 
softened,  and  a  very  large  abscess  soon  declared  itself,  involv- 
ing the  whole  calcaneal  region.  This  soon  broke,  and  dis- 
charged freely  from  two  openings.  These  openings,  which 
were  on  the  side  of  the  os  calcis,  had  been  laid  into  one,  thus 
exposing  the  bone  to  easy  exploration  with  the  finger.  An 
abscess  was  found  surrounding  the  whole  of  the  os  calcis,  and 
the  finger  could  be  passed  around  so  as  to  touch  the  bare  and 
evidently  dead  bone  on  all  sides.  The  disease  was  confined, 
as  far  as  we  could  judge,  to  the  os  calcis,  which  was  already 
loosened  in  its  attachments,  both  to  the  astragalus  and  to  the 
cuboi'd.  There  was  great  thickening  and  induration  of  the 
soft  parts  forming  the  walls  of  the  abscess,  and  a  very  large 
discharge  of  pus.  He  suffered  much  from  pain,  and  was  rap- 
idly depreciating  in  general  health. 

Regarding  the  case  as  one  of  entire  necrosis  of  the  os  calcis, 
and  believing  that  the  destruction  was  confined  to  that  bone,  I 
heartily  concurred  in  Dr.  Little's  proposal  to  remove  the  dead 
bone,  instead  of  amputating  the  limb.  It  was  done  by  Dr. 
Little  without  difficulty,  by  making  a  free  opening,  so  as  to 
get  control  of  the  bone ;  and  then,  carefully  separating  its  liga- 
mentous  attachments,  it  was  easily  removed.  As  far  as  could 
be  ascertained,  the  parts  left  behind  were  in  a  sound  condition. 
No  evil  behavior  showed  itself  in  the  healing  of  the  wound. 
Granulation  took  place  slowly,  and  the  wound  filled  up  with 
new  material,  the  shape  and  size  of  the  heel  being  in  a  good 
degree  preserved.  This,  Dr.  Little  informed  me,  finally  con- 
solidated by  bone,  so  as  to  afford  a  very  good  instance  of  re- 
generation of  bone  from  its  periosteum. 

3.  The  third  variety  of  necrosis  which  I  deem  worthy  of  spe- 
cial study  is  that  which  occurs  in  the  cranial  bones.  It  is  not 
easy  to  say  why  the  disease  should  differ  in  its  behavior  in 
these  bones  from  the  course  it  presents  elsewhere  ;  but  that  it 
does  so  is  abundantly  manifest.  The  most  striking  peculiari- 
ties of  necrosis  in  this  situation  are  mainly  two  :  1.  An  indis- 
position to  the  separation  and  casting  off  of  the  dead  bone.  2. 
A  disposition  to  spread  slowly  and  gradually,  so  as  to  invade 
large  tracts  of  neighboring  healthy  bone.  These  two  features 
render  this  a  formidable  disease ;  and,  as  they  directly  interfere 


158  DISEASES  OF  BONE. 

•with  the  reparative  action  of  the  diseased  part,  will  explain  why 
it  is  that  necrosis  of  the  cranial  bones  is  so  frequently  a  fatal 
disorder.  It  is  mostly  as  a  consequence  of  syphilis  that  this 
peculiar  form  of  necrosis  arises ;  but  I  have  reason  to  believe 
that  in  other  cachectic  conditions  of  the  system,  when  no 
syphilitic  history  can  be  traced,  more  or  less  of  the  same  pe- 
culiarities occasionally  show  themselves.  I  can  best  illustrate 
the  disease  by  giving  a  typical  case,  which  was  undisturbed  by 
surgical  treatment.  "While  at  Fortress  Monroe,  in  the  spring 
of  1862,  McClellan's  army  then  lying  before  Yorktown,  I  was 
asked  to  see  an  officer  of  the  regular  army,  who  was  suffering 
from  syphilitic  rupia.  I  found  a  young  gentleman  covered 
with  large  crusts  of  rupia,  and  so  reduced  that  he  was  obliged 
to  keep  his  bed.  He  was  unable  to  go  on  with  the  army,  and 
finally  was  sent  home,  and  he  came  under  my  care  in  New 
York.  His  case  was  a  most  difficult  and  distressing  one,  from 
the  extent  and  severity  of  the  ulceratiou  following  the  falling 
of  the  scabs.  He  partly  recovered  under  the  use  of  liberal 
doses  of  iodide  of  potassium,  and  was  able  to  go  to  his  home 
in  the  country.  I  saw  him  again  in  the  next  year,  greatly 
improved,  but  not  well.  I  lost  sight  of  him  then  for  several 
years,  when  my  old  friend  turned  up  in  the  wards  of  the  New 
York  Hospital,  in  June,  1868.  I  was  shocked  to  see  him  cov- 
ered with  sores  and  scabs  and  scars,  emaciated  to  a  skeleton, 
his  voice  altered  by  the  destruction  of  part  of  the  palate,  and 
it  was  long  before  I  could  believe  him  to  be  the  same  man. 
He  was  in  a  deplorable  condition  ;  but  the  most  alarming  fea- 
ture to  me  was  the  condition  of  his  head.  The  scalp  presented 
at  several  points  large  ulcerations,  covering  altogether  one- 
half  of  its  surface.  The  bottom  of  these  ulcers  was  constituted 
by  the  bare,  dead,  and  blackened  surface  of  the  cranium, 
which  was  manifestly  in  a  condition  of  necrosis  over  at  least 
one-half  of  the  vault.  Exuberant  but  pale  granulations  sur- 
rounded these  very  irregular  patches  of  necrosis,  and  an  abun- 
dant fetid  discharge  flowed  from  their  surface.  Some  of  this 
discharge,  however,  came  from  beneath  the  bone,  where  there 

O      7  7  ' 

were  several  irregular,  worm-eaten  looking  perforations  through 
the  dead  layer.  On  pushing  back  the  granulations,  healthy 
living  bone  could  easily  be  brought  into  view,  and  a  line 


NECROSIS.  159 

somewhat  distinct  could  be  traced  between  the  dead  and  living 
parts,  which  at  some  points  showed  a  disposition  to  separation, 
so  that  at  one  or  two  points  along  this  edge  considerable  exca- 
vations, of  a  very  irregular  outline  and  of  varying  depth,  could 
be  seen,  some  of  them  penetrating  the  skull,  and  giving  issue 
to  pus,  which  evidently  came  from  beneath  the  bone.  In  all 
the  rest  of  the  line  no  distinct  evidence  could  be  traced  of  any 
attempt  at  separation  of  the  dead  from  the  living  tissue.  The 
bone  in  the  immediate  neighborhood  of  the  dead  tissue  showed, 
at  some  points,  an  increased  vascularity,  but  no  other  change. 
This  condition  had  been  brought  about  by  a  series  of  morbid 
actions,  commencing  a  little  more  than  a  year  ago.  The  first 
thing  noticed  was  a  small,  painful,  and  tender  swelling,  several 
others  showing  themselves  nearly  at  the  same  time.  These 
increased,  soon  suppurated  and  ulcerated,  and  at  a  very  early 
period  presented  dead  bone  on  their  floor.  A  great  deal  of 
pain  attended  these  ulcerations,  and  made  it  difficult  for  him 
to  place  his  head  on  his  pillow  without  suffering.  His  general 
feebleness,  and  the  long  continuance  and  inveterate  behavior 
of  his  disease,  made  his  case  so  hopeless  that  nothing  could  be 
done  except  by  a  cordial  and  invigorating  regimen,  with  ano- 
dynes in  full  doses,  to  try  to  rouse  up  his  failing  powers.  But 
little  was  accomplished,  however,  and  he  left  the  hospital  in 
the  latter  part  of  August  for  his  home,  to  die  a  few  days  after 
he  reached  it,  with  symptoms  of  inflammation  of  the  brain  or 
its  meninges. 

Here  no  surgical  operation  was  at  any  time  practicable, 
and  the  disease  followed,  therefore,  an  undisturbed  course.  In 
the  following  cases  removal  of  the  dead  bone  was  practised, 
with  a  result  which,  though  varying  a  little  in  different  cases, 
is,  on  the  whole,  far  from  encouraging : 

Sarah  Atwood,  aged  twenty-four,  was  admitted  to  the  New 
York  Hospital,  June  14,  1859,  with  a  diseased  condition  of  the 
bones  of  the  forehead.  Six  years  before  she  had  had  syphilis, 
not  followed  by  any  secondary  symptoms.  About  a  year  after- 
ward she  suffered  much  from  headache,  followed  by  the  appear- 
ance of  painful  swellings  on  the  front  part  of  the  head,  which, 
after  about  six  months,  softened  and  suppurated.  New  open- 
ings have  since  formed,  and  all  have  continued  to  discharge. 


160  DISEASES  OF  BONE. 

showing  no  inclination  to  heal.  Her  general  condition  13 
good,  and  she  has^  no  other  secondary  manifestations.  Five 
fistulous  openings  now  exist  on  the  anterior  part  of  the  os 
frontis,  at  the  bottom  of  each  of  which  the  probe  detects  bare 
and  rough  bone.  On  the  18th  of  June  the  late  Dr.  John  Wat- 
son, then  in  attendance,  made  an  incision  through  the  line  of 
ulcers,  and  laid  up  a  flap  exposing  the  diseased  surface,  which 
occupied  at  least  six  square  inches.  The  periosteum  was  so 
easily  stripped  off  from  the  bone  that  it  was  evident  it  could 
have  had  no  vital  connection  with  it.  The  surface  of  the  dis- 
eased bone  was  rough  and  irregular,  and  raised  from  its  proper 
level  by  elevations  and  bosses,  which  showed  that  a  process  of 
thickening  had  been  going  on.  Several  openings  presented 
themselves  in  the  midst  of  the  diseased  region,  from  which 
pus  flowed  out,  evidently  from  a  space  between  the  bone  and 
the  dura  mater.  It  seemed,  from  the  altered  color  and  the 
bloodlessness  of  the  part,  that  it  was  entirely  dead  ;  and  when 
the  periosteum  was  still  further  stripped  up,  so  as  to  expose 
the  surrounding  healthy  bone,  the  contrast  was  very  marked. 
No  line  of  separation,  however,  showed  itself  at  any  point ; 
and  this  seemed  the  more  remarkable,  as  there  was  reason  to 
believe  that  the  death  of  the  bone  had  occurred  at  least  three 
years  previously.  It  was  determined  to  remove  all  the  dead 
bone,  and  this  was  done,  after  long  and  patient  perseverance, 
in  chiselling  and  gouging  and  gnawing  the  dead  bone  until 
living  bone  was  reached.  In  this  way  the  whole  dead  portion 
was  removed,  sometimes  consisting  of  a  superficial  layer,  not 
involving  the  inner  table ;  at  other  points  involving  the  whole 
thickness  of  the  skull,  and  leaving  exposed  the  granulating 
surface  of  the  dura  mater. 

The  behavior  of  the  wound  was  very  satisfactory.  Granu- 
lations sprung  up  freely  from  the  dura  mater  and  from  the 
gnawed  surface  of  the  bone.  Toward  the  close  of  July  two 
firm  and  hard  swellings  occurred  on  the  parietal  bone,  near  the 
wound,  one  of  which  suppurated  and  discharged  through  the 
wound,  and  the  other  disappeared  without  suppuration.  No 
necrosis  followed  at  this  time.  About  the  8th  of  September  two 
sequestra,  of  an  irregular  form,  and  together  larger  than  a 
quarter  of  a  dollar,  separated  from  under  the  still-open  edge 


NECROSIS.  161 

of  the  wound.  These  pieces,  on  examination,  proved  to  be 
from  the  margin  of  the  surface  left  after  the  operation,  as  they 
showed  the  marks  of  the  rongeur.  This  must  have  been,  there- 
fore, a  spread  of  the  necrosis  after  the  operation ;  but  it  is  well 
worthy  of  remark  that  Nature  had  been  able,  under  the  altered 
conditions  induced  by  the  operation,  to  effect  a  separation  in  a 
few  weeks,  which  she  had  not  been  able  to  accomplish  during 
the  previous  three  years.  No  sign  of  cerebral  disturbance 
showed  itself  after  the  operation  at  any  time.  November  \st. — 
All  has  gone  on  favorably ;  the  cavities  left  in  the  operation 
being  filled  up  and  nearly  healed.  Unfortunately,  however, 
there  is  too  much  reason  to  fear  that  the  original  disease  is 
progressing,  and  thus  far  it  is  not  controlled  by  remedies. 
New  districts  of  bone  were  being  invaded  by  the  disease  when 
she  was  discharged,  January  9,  1860. 

This  was  the  first  case  of  the  kind  I  had  studied,  and  I  was 
much  disappointed  at  its  treacherous  behavior.  The  first 
favorable  progress  had  not  led  me  to  expect  that  its  ravages 
would  be  resumed,  even  during  the  apparently  healthful  heal- 
ing of  the  wound.  I  was  not  so  much  surprised,  therefore, 
when  in  the  next  case  which  occurred  I  found  a  similar  dispo- 
sition. 

James  Hughes,  aged  twenty-seven,  was  admitted  into  the 
New  York  Hospital,  January  25,  1865,  with  necrosis  of  the 
bones  of  the  cranium.  He  had  had  chancre  and  bubo  eight 
years  before,  the  bubo  suppurating.  No  evident  symptoms  of 
secondary  syphilis  followed,  though  at  various  times  he  had 
suffered  much  fronnpains  in  the  bones.  Some  months  previous 
to  his  admission,  he  found  a  painful  swelling  on  his  forehead, 
and  soon  after  another  on  the  vertex,  and  another  on  the  right 
side  behind  the  ear.  These  sluggishly  enlarged,  and,  after 
about  six  months,  opened  and  discharged  pus.  The  wounds 
have  never  healed.  The  orifices  were  pouting,  and  the  probe 
detected  dead  bone  over  a  considerable  surface,  covered  by  un- 
dermined integument.  An  operation  was  performed  on  the 
vertex,  which  was  the  point  most  extensively  diseased,  in  the 
latter  part  of  1865.  The  bone  was  exposed,  and  the  diseased 
area  was  found  to  embrace  about  two  square  inches,  of  an  oval 
form.  This  was  bare  of  periosteum,  of  a  brownish  color,  and 
11 


162 


DISEASES  OF   BONE. 


evidently  dead.  The  living  was  separated  from  the  dead  bone 
by  a  line  of  demarcation,  which  was  tolerably  distinct,  but 
which  showed  no  evidence  at  any  point  that  separation  had 
commenced.  With  the  rongeur  the  dead  bone  was  thoroughly 
gnawed  away,  till,  at  all  points,  living,  bleeding  bone  was 
reached.  The  wound  was  dressed  lightly.  Imperfect  attempts 
at  granulation  were  observed  for  a  time,  but  it  soon  became 
evident  that  the  whole  surface  of  the  wound  was  dead,  and 
that  the  necrosis  was  extending.  He  left  the  hospital  in  De- 
cember, 1865,  and  soon  after  entered  Bellevue  Hospital.  After 
he  had  been  in  Bellevue  about  a  year,  the  disease  having,  in 
the  mean  time,  spread  very  extensively,  Dr.  F.  H.  Hamilton 


FIG.  24. — (Bellevue  Hospital  Museum.) 

performed  an  operation,  November  26,  1866,  for  the  removal 
of  the  dead  bone,  hoping  that  by  this  time,  nearly  two  years 
having  elapsed  since  the  commencement  of  the  disease,  separa- 
tion would  have  taken  place.  To  some  extent  his  anticipations 
proved  correct ;  and  one  large  piece,  including  the  whole  ver- 
tex, came  away  almost  without  difficulty.  At  some  points, 
however,  even  of  this  piece,  the  separation  was  not  complete, 
and  the  bone  had  to  be  broken  in  order  to  remove  it.  At  sev- 


NECROSIS.  163 

eral  other  periods  similar  operations  were  performed,  removing 
larger  or  smaller  pieces  of  partially-separated  dead  bone,  a 
great  part  of  the  bone  removed  embracing  both  tables  of  the 
skull. 

His  present  condition,  July,  1868,  shows  all  the  central 
part  of  the  crown  of  the  head  occupied  by  a  depressed  scar,  as 
large  as  the  palm  of  the  hand.  Of  this  scar,  a  portion  about 
two  inches  by  three  evidently  has  no  bone  underneath  it,  the 
whole  thickness  of  the  cranium  having  here  been  removed. 
The  movements  of  the  brain  can  be  felt  and  seen  at  this  point. 
Some  irregular  ossification  has  taken  place  in  this  central 
space;  but,  where  this  is  found,  some  hair  is  growing,  showing 
that  at  these  points  the  integuments,  and  therefore  probably 
the  pericranium,  had  been  preserved.  On  the  right  side  of 
this  central  scar,  which  seems  soundly  healed,  are  numerous 
openings,  which  lead  down  to  dead  bone,  showing  that,  after 
the  lapse  of  four  years,  the  progress  of  the  disease  is  not 
arrested.  His  general  health  is  good.  No  signs  of  syphilitic 
disease. 

The  portions  removed  in  the  two  largest  pieces  embrace 
about  ten  square  inches,  of  an  irregular  square  shape,  extend- 
ing on  either  side  of  the  median  line,  the  sagittal  suture  run- 
ning through  nearly  its  middle.  The  surfaces  are  irregular,  as 
if  worm-eaten,  which  is  still  more  marked  on  the  edges.  The 
largest  portion  of  each  of  these  two  pieces  shows  that  the  dis- 
ease has  embraced  both  tables  of  the  skull.  The  signs  of  the 
original  gnawing  operation  are  seen  in  the  upper  surface  of  the 
removed  sequestrum,  and  the  external  surface  around  this  point 
is  deeply  stained  of  a  brownish-black  color  (Fig.  24). 

A  third  case  occurred  in  the  hospital  service  of  Dr.  Gurdon 
Buck.  John  Roberts,  aged  thirty-three,  was  admitted  into  the 
New  York  Hospital,  January  18,  1868,  with  extensive  necrosis 
of  the  skull.  Twelve  years  before,  he  had  had  a  chancre,  fol- 
lowed by  a  non-suppurating  bubo.  Secondary  symptoms  en- 
sued, eruptions  on  the  skin,  sore  throat,  loss  of  uvula,  and 
pains  in  the  bones.  About  ten  months  before  his  admission,  a 
reddish  swelling  commenced  on  his  forehead,  which  suppurated 
slowly,  breaking  and  discharging  pus  about  eight  months  after 
its  commencement.  Similar  sores  have  since  appeared  at  inter- 


164  DISEASES   OF  BONE. 

vals,  scattered  on  the  top  of  the  head.  His  general  health  has 
been  good.  On  admission  there  were  numerous  undermined 
ulcers  scattered  over  the  front  and  upper  part  of  the  head, 
varying  in  size  from  that  of  a  pea  to  that  of  a  dollar,  and  all 
presenting  dead  bone  more  or  less  exposed  to  view.  The  dis- 
charge was  considerable,  and  fetid.  The  surface  of  the  dead 
bone  has  not  the  smooth,  even  appearance  of  a  bone  which  has 
died  in  full  health,  but  gives  evidence,  by  its  roughness  and 
irregular  erosions,  that  some  changes,  probably  inflammatory, 
have  preceded  its  actual  death.  Some  of  these  erosions  pene- 
trate the  thickness  of  the  skull,  and  give  issue  to  matter  from 
beneath  the  bone.  At  these  points  the  pulsations  of  the  brain  can 
be  seen.  On  the  24th  of  January  Dr.  Buck  proceeded  to  an 
operation  in  which  he  proposed  to  remove  all  of  the  dead  bone 
which  could  be  safely  got  away.  Several  of  the  anterior  ulcers 
were  laid  into  one  by  communicating  incisions,  and  the  flaps 
raised,  thus  exposing  largely  the  diseased  surfaces.  It  was  found 
that  the  whole  surface  was  dead  ;  but,  though  a  line  of  demarca- 
tion could  be  distinctly  traced,  separation  had  taken  place  at  but 
few  points.  The  bone  in  the  immediate  neighborhood  seemed 
perfectly  healthy.  With  the  rongeur  principally,  by  a  mixed 
process  of  breaking  and  cutting,  the  whole  of  the  cranial  por- 
tion of  the  frontal  half  of  each  parietal,  and  a  portion  of  each 
temporal  bone,  were  removed,  exposing  the  dura  mater  over  the 
whole  of  this  extensive  surface.  This  membrane  was  thick- 
ened and  granulating.  The  posterior  half  of  the  vault  of  the 
cranium,  which  was  found  to  be  in  the  same  condition,  was  re- 
served for  a  future  operation. 

For  a  few  days  after  the  operation,  all  went  on  well,  and 
the  wound  put  on  a  healthy,  reparative  appearance.  On  the 
1st  of  February,  however,  he  had  a  chill,  followed  by  fever. 
This  was  repeated  after  several  days.  Gradually  headache  and 
blindness  came  on,  and  soon  after  convulsions,  coma,  and  death 
on  the  18th  of  February. 

Inflammation  of  the  meninges  was  found,  on  post-mortem 
examination,  with  numerous  small  abscesses  scattered  through 
the  most  superficial  portion  of  the  brain-substance.  The  ne- 
crosis was  found  even  more  extensive  than  we  had  supposed, 
occupying  the  whole  of  the  cranial  vault  (Fig.  25). 


NECROSIS.  165 

Several  other  cases  of  this  formidable  disease  have  occurred 
under  my  observation,  but  these  seem  sufficient  to  illustrate  its 
clinical  features.  I  have  tried  to  trace  the  processes  preceding 
death  of  the  bone  in  several  of  these  cases,  but  can  only  say 
that  it  seems  to  be  a  slow  process  of  inflammation,  in  which 


FIG.  25.— (X.  T.  Hospital  Museum.) 

sometimes  a  mere  vascularity  of  the  bone  about  to  die  is  de- 
tected ;  in  other  cases  the  bone  is  thickened  ;  in  others  a  deposit 
of  a  granular,  pumice-like  appearance  takes  place  on  the  sur- 
face, but  whether  from  the  bone  before  its  death  or  from  the 
living  tissues  after  death,  I  have  not  yet  been  able  to  detect. 
Again,  erosions  and  ulcerations  of  the  diseased  bone  are  dis- 
covered, which  must  of  course  have  taken  place  before  actual 
death  has  occurred  ;  but  the  whole  process  is  so  gradual  that 
it  is  not  easy  to  pronounce  at  any  moment  what  part  of  the 
bone  is  still  alive  and  active,  and  what  is  dead  and  unchanging. 
That  the  peculiarities  of  the  disease  now  described  depend 
upon  some  constitutional  vice,  and  not  upon  the  pathological 
dispositions  of  the  cranial  bones,  would  seem  to  be  clearly 
shown  by  the  behavior  of  these  same  bones  under  other  condi- 


166  DISEASES  OF   BONE. 

tions.  Thus  simple  traumatic  causes  produce,  in  the  cranium, 
a  necrosis  which  differs  in  none  of  its  clinical  features  from 
necrosis  occurring  elsewhere.  For  example:  John  Murphy, 
aged  twenty-six,  in  June,  1868,  struck  the  top  of  his  head,  in 
rising  from  a  stooping  position,  against  the  iron  surface  of  some 
machinery  he  was  engaged  in  oiling.  The  contused  part  in- 
flamed and  formed  an  abscess,  which,  after  discharging,  refilled 
and  continued  to  close  and  open  several  times.  He  came  to 
the  New  York  Hospital  in  August,  about  two  months  after  the 
injury,  with  the  wound  still  unhealed.  The  probe  detected 
dead  bone.  Another  opening  formed,  leaving  a  considerable 
space  between  the  two  orifices  where  the  undermined  integu- 
ment covered  bare  bone.  On  the  22d  of  September  an  incision 
was  made  joining  the  two  openings,  and  then  extended  so  as 
to  expose  the  dead  surface.  It  was  found  nearly  round  in 
shape,  and  about  two  square  inches  in  size.  A  probe  intro- 
duced under  the  edge  of  the  sequestrum,  which  showed  clear 
evidences  of  separation,  loosened  the  whole  piece,  and  it  came 
away  entire.  The  main  portion  of  this  piece  was  a  thin  plate 
comprising  the  outer  table  only,  but  at  several  points  the  whole 
thickness  of  the  bone  was  involved  at  these  points.  In  the 
granulating  bed,  from  which  it  was  removed,  the  pulsations  of 
the  brain  could  be  seen.  The  wound  healed  rapidly,  and  the 
patient  was  discharged  cured.  In  another  case,  a  man  was 
brought  to  the  hospital,  wounded  by  a  pistol-ball  at  the  upper 
and  posterior  part  of  the  neck.  In  trying  to  trace  the  ball,  it 
was  found  to  have  sunk  down  deep  in  the  muscular  mass  be- 
tween the  occiput  and  atlas,  but  we  could  not  find  it.  Great 
inflammation  and  extensive  suppuration  followed,  and,  after 
many  weeks,  dead  bone  could  be  felt  by  the  probe.  In  due 
time  an  operation  was  done  by  Dr.  H.  B.  Sands,  by  which  the 
occiput  was  exposed  by  a  long  incision,  the  muscles  being 
partly  incised  and  partly  detached.  It  was  found  that  the 
bottom  of  the  wound  was  formed  by  the  occipital  bone  in  a 
condition  of  necrosis,  and  that  the  sequestrum  was  already 
loose.  By  careful  manipulation  the  whole  piece  was  extracted 
in  shape  and  size  much  resembling  the  squamous  portion  of 
the  temporal  bone,  and  some  of  it  embracing  both  tables  of 
the  skull.  In  the  centre  of  the  piece  removed  was  found  the 


NECROSIS.  167 

opening  made  by  the  ball,  which  was  also  found  lying  loose  in 
the  wound.  The  man  made  a  rapid  recovery. 

Again,  as  illustrating  another  form  of  necrosis  of  the  skull, 
a  man  was  struck  at  the  battle  of  New  Orleans  by  a  glancing 
ball  which  bruised  the  vertex  without  breaking  the  skin. 
Abscess  formed  at  the  injured  point  and  remained  unhealed. 
Some  months  after,  I  saw  him,  and,  finding  dead  bone,  made 
an  incision  and  removed  several  pieces,  embracing  the  whole 
thickness  of  the  bone,  which,  from  the  cleanness  of  their  edges, 
were  undoubtedly  fragments  which  had  been  broken  by  the 
original  blow  and  had  subsequently  died. 

With  regard  to  treatment,  these  simple  traumatic  cases  are 
satisfactory  enough;  but  in  the  constitutional  form  my  own 
experience  is  not  encouraging.  None  of  the  usual  remedies 
employed  have  seemed  to  exert  any  influence  on  its  course,  and 
surgical  interference  is  apparently  able  to  eifect  only  the  re- 
moval of  the  consequences  of  the  disease,  without  arresting  its 
progress.  It  is  true,  perhaps,  that  in  the  hopes  of  spontaneous 
separation  we  have  wasted  time  and  abated  effort  in  the  admin- 
istration of  remedies ;  and  it  is  much  to  be  hoped  that  some- 
thing may  yet  be  discovered  that  will  at  least  control  the  march 
of  this  obstinate  and  dangerous  disorder ;  but  thus  far  I  have 
no  evidence  that  any  remedy  has  any  positive  influence  in 
arresting  its  fatal  march. 

The  following  case  I  condense  from  Dr.  Agnew's  report, 
who  kindly  sent  me  the  specimens  from  which  the  figures  are 
taken :  W.  C.,  aged  thirty-eight,  had  suffered  with  otitis 
media  of  both  ears  from  the  age  of  six  years.  He  retained  his 
hearing  partially  until  about  three  years  before  Dr.  Agnew 
saw  him,  when  an  acute  attack  of  deep-seated  and  very  severe 
inflammation  in  the  right  ear  terminated  in  complete  deafness, 
accompanied  with  paralysis  of  the  portio  dura  of  that  side. 

"  The  patient  came  under  my  observation  for  the  first  time 
on  the  16th  of  April,  1862,  presenting  evidences  of  great  suf- 
fering and  debility.  He  had  suffered  greatly  for  months  from 
gnawing  pain  in  the  ear,  insomnia,  loss  of  appetite,  and  dizzi- 
ness. An  examination  of  the  external  ear  was  effected  with 
great  difficulty,  on  account  of  its  excessive  tenderness.  The 
concha,  swollen  and  inflamed,  was  elevated  by  a  dense  inflam- 


168  DISEASES  OF  BONE. 

matory  tumefaction,  circumscribing  the  external  meatus,  ex- 
tending backward  over  the  mastoid  process,  and  forward 
along  the  zygoma.  Projecting  from  the  meatus  was  a  large 
pear-shaped  polypus  of  a  dense  fibrous  character,  bathed  by  a 
constant  flow  of  stinking  pus.  Desiring  to  get  to  the  bottom 
of  the  case,  I  placed  the  patient  under  chloroform,  and  removed 
the  polypoid  mass  by  means  of  a  wire  snare. 
In  attempting  to  push  the  snare  to  the  bottom 
of  the  meatus,  I  encountered  a  solid  obstacle 
in  the  region  of  the  middle  ear,  which  subse- 
quently proved  to  be  the  sequestrum,  repre- 
sented by  the  accompanying  woodcut.  The 
calibre  of  the  external  meatus  had  been  much 
reduced  by  boggy  swelling  of  its  soft  parts,  so 
that  I  was  compelled  to  make  as  free  an  incision 
as  possible  to  enable  me  to  reach  the  sequestrum 
with  a  pair  of  small  dressing-forceps.  Having 
got  the  body  in  the  grasp  of  the  forceps,  a  slight  rocking  motion 
with  traction  enabled  me  to  extract  it. 

"  It  will  be  observed  that  the  sequestrum  includes  the  wreck 
of  the  labyrinth.  The  cochlea  is  shown  laid  open  by  caries, 
and  two  of  the  semicircular  canals  are  seen  in  part.  The  loss 
of  hearing  and  paralysis  of  the  seventh  pair  were  explained. 
Two  views  in  fac-simile  are  given  of  the  sequestrum  in  the 
woodcut,  and  an  attempt  has  been  made  by  the  artist  to  repre- 
sent the  eroded  appearances.  The  remains  of  the  anterior 
semicircular  canal  are  indicated  by  the  letter  C;  and  the 
cochlea  B,  opened  by  caries,  shows  the  lamina  spiralis.  The 
vestibule  is  bereft  of  its  furniture  and  almost  obliterated. 

"After  the  operation  the  patient  rapidly  regained  his  health, 
and  by  the  3d  of  January,  1863,  the  external  meatus  had  be- 
come closed  by  cicatrization.  The  paralysis  still  remains." 

The  patient  wTas  subsequently  seized  with  an  acute  otitis 
interna  of  the  left  ear,  which  went  on  to  suppuration,  and 
proved  fatal  by  extension  of  the  inflammation  to  the  brain. 
On  post  mortem  the  dura  mater  covering  the  petrous  portion 
of  the  temporal  bone  was  very  much  thickened,  and  a  small 
abscess  was  found  in  the  brain  immediately  above  the  diseased 
bone.  Fig.  27  shows  the  appearance  of  each  external  meatus 


NECROSIS. 


1G9 


after  maceration.  Both  of  them  are  enlarged  and  irregular, 
from  carious  ulceration,  and  one  of  them  almost  closed  by  an 
osseous  growth,  as  large  as  a  pea,  springing  from  the  ulcerated 
margin  of  the  meatus.  Smaller  exostoses  of  the  same  kind 
are  forming  at  several  other  points  round  each  meatus. 


FIG.  27. — (From  a  specimen  in  Dr.  Agnew's  collection.) 

A  fourth  class  of  cases  worthy  of  special  study  embraces 
those  which  occur  in  the  jawbones.  Of  the  cases  of  necrosis 
occurring  in  these  bones  we  have  a  great  variety,  which  differ 
in  no  important  respect  from  cases  of  necrosis  elsewhere.  We 
have  among  them,  however,  two  special  classes  requiring  par- 
ticular mention,  and  these — 1.  Those  occurring  in  consequence 
of  the  eruptive  fevers.  2.  Those  arising  from  the  poison  of 
phosphorus.  The  cases  occurring  after  eruptive  fevers  were 
first  brought  to  the  notice  of  the  profession  by  S.  I.  A.  Salter, 
in  a  paper  published  in  Guy's  Hospital  Reports.  Their  de- 
pendence as  a  cause  upon  the  eruptive  disease  he  considers 
proved  by  their  almost  invariable  association,  and  he  gives  the 
following  account  of  the  symptoms:  "A  little  child  has  just 
recovered  from  one  of  the  eruptive  fevers,  most  probably  scar- 
latina ;  the  case  has  been  in  no  'way  unusual  as  to  its  severity 
or  its  course :  within  six  weeks  or  two  months  of  the  passing 
off  of  the  acute  symptoms,  tenderness  of  the  mouth  is  com- 
plained of,  and  the  mother  notices  fetor  of  the  breath.  Upon 
inspecting  the  mouth,  the  gum  is  seen  to  be  peeling  from  the 
edge  of  the  jaw  around  the  neck  or  necks  of  some  temporary 
tooth  or  teeth ;  pus  is  discharging,  and  more  or  less  dead  bone 
is  exposed.  The  denudation  of  bone  progresses  rather  quickly 
in  depth,  but  usually  not,  after  the  first,  in  lateral  extent;  the 


170  DISEASES   OF  BONE. 

temporary  teeth  at  the  affected  part  become  loose  and  often 
fall  out.  There  is  no  swelling,  and  no  ossifying  callus  is  formed 
in  the  region  of  the  necrosed  bone.  In  a  few  weeks  from  the 
first  of  these  symptoms,  the  sequestrum  itself  becomes  loose, 
and  is  easily  removed,  leaving  a  large  gap  and  a  raw  granu- 
lating surface  which  rapidly  heals.  The  necrosis  almost  always 
includes  the  bone  which  constitutes  the  loculi  containing  the 
developing  permanent  teeth,  as  well  as  the  alveoli  of  the  tem- 
porary ;  but  it  does  not  go  farther,  and  in  the  lower  jaw  the 
base  of  the  bone  is  very  rarely  affected."  Mr.  Salter  further 
states  that  this  affection  occurs  only  after  the  eruptive  fevers, 
and  that  it  attacks  children  from  three  to  eight  years  of  age. 
He  regards  it  as  a  self-limiting  disorder,  requiring  only  such  treat- 
ment as  local  cleanliness  and  general  supporting  regimen.  The 
resulting  deformity  arises  principally  from  the  loss  of  the  teeth. 
The  eases  of  necrosis  of  the  jaws  from  exposure  to  the  fumes 
of  phosphorus  make  a  much  more  interesting  and  a  much  more 
important  class,  and  have  during  the  past  few  years  attracted  a 
great  deal  of  attention.  They  present  themselves,  almost  ex- 
clusively, among  the  operatives  in  the  match-manufactories, 
and  only  in  those  who  have  been  long  exposed  to  the  poisonous 
emanations.  The  substance  which  acts  as  the  producing  cause 
of  the  mischief  is  undoubtedly  phosphorus-vapor,  usually  ex- 
isting as  phosphorous  and  phosphoric  acid  with  probably  some 
free  phosphorus.  It  was  at  one  time  thought  that  arsenic  was, 
in  some  degree  at  least,  connected  with  the  production  of  the 
necrosis,  this  substance  being  contained  in  some  ordinary  and 
impure  specimens  of  phosphorus.  This  suspicion  has  not  been 
verified,  and  it  is  now,  after  careful  investigation,  believed  that 
the  phosphorus  alone  is  the  poisonous  agent.  The  efficient 
action  of  the  cause  seems  to  depend  mainly  on  two  things: 
first,  a  long-continued  exposure  to  the  poison  ;  and,  secondly, 
some  condition,  either  of  the  teeth  or  gums,  which  favors  the 
entrance  of  the  poison  into  direct  contact  with  the  tissues.  In 
regard  to  the  first,  writers  are  unanimous  as  to  the  fact  that 
it  is  only  after  very  prolonged  exposure  that  necrosis  occurs,  so 
much  so  that  there  are  scarcely  any  cases  on  record  in  which 
some  years  have  not  elapsed  before  the  disease  developed  itself. 
The  dangerous  exposure  takes  place  in  only  two  departments 


•   NECROSIS.  171 

of  the  manufacture,  viz.,  the  dipping-room,  and  the  counting 
and  packing  rooms.  In  these  the  patients  are  subjected  to  an 
atmosphere  constantly  impregnated  with  the  fumes  of  phos- 
phorus, and  this  air  is  still  further  contaminated  by  the  frequent 
catching  tire  of  the  matches,  which  generates  a  large  quantity 
of  phosphorous  acid,  and  that,  too,  in  the  immediate  neighbor- 
hood of  the  face  of  the  patient,  so  that  it  is  extremely  easy  for 
the  poisonous  fumes,  which  are  quite  soluble  in  water,  to  come 
in  direct  contact  with  the  mucous  membranes  of  the  mouth 
and  nose,  and  also  with  the  bronchial  mucous  surface.  Why 
the  poison  of  phosphorus  does  not  affect  the  Sclmeiderian  and 
bronchial  mucous  membrane  does  not  appear;  but  the  fact  is 
stated  by  Von  Bibra  and  Geist,  whose  work  on  this  subject  is  the 
most  complete  we  have,  that  there  is,  among  the  patients  thus 
exposed,  no  special  tendency  to  bronchial  or  nasal  catarrh,  and 
no  effects  are  noticed  on  the  bone  upon  which  parts  of  these 
membranes  are  spread.  These  effects  seem  to  be  reserved  for 
the  bones  of  the  upper  and  lower  jaw,  and  in  these  bones,  after 
a  prolonged  exposure  to  the  poison,  the  first  symptoms  of  the 
disease  appear. 

But,  secondly,  it  would  appear  that  something  besides  this 
exposure  is  necessary  to  produce  the  disease,  and  this  something 
is  a  carious  condition  of  the  teeth,  or  an  ulcerated  condition 
of  the  gums.  It  was  early  observed  that  this  condition  of  the 
mouth  was  a  predisposing  cause  of  the  disease,  but  it  was  only 
after  long  observation  of  accumulating  cases  that  it  was  shown 
to  be  a  uniform  and  an  indispensably  exciting  cause.  None  of 
those  whose  teeth  were  perfect,  and  whose  gums  were  sound, 
were  ever  attacked,  while  soundness  was  maintained,  but  if 
caries  attacked  the  teeth,  or  ulceration  the  gums,  or,  worse  than 
all,  if  a  tooth  had  been  recently  extracted,  then  the  persons  so 
affected  became  liable  to  the  development  of  the  disease.  From 
the  slow  action  of  such  a  cause  one  would  be  led  to  anticipate 
that  some  evidence  of  constitutional  vitiation  would  precede 
the  local  manifestation.  This  does  not  seem  to  be  so,  and 
those  who  suffer  most  are  oftentimes  the  most  vigorous  and 
healthy  of  the  workmen,  maintaining  every  indication  of  con- 
stitutional soundness  up  to  the  moment  when  the  local  disease 
begins  to  infect  and  involve  the  general  system. 


1Y2  DISEASES   OF  BONE. 

The  first  symptoms  of  the  disease,  then,  are  strictly  local. 
A  toothache  is  generally  the  first  complaint,  and  this  may  be 
intermittent,  returning  at  irregular  intervals,  until  it  becomes 
a  constant  and  very  distressing  symptom,  spreading  over  the 
whole  side  of  the  face.  The  gums  now  begin  to  inflame  and 
ulcerate,  and  the  parts  about  the  jaw  become  tumefied.  In- 
flammation of  the  whole  affected  part  is  now  active,  and  soon 
an  abscess  forms,  usually  discharging  itself  alongside  of  one  of 
the  teeth  through  the  ulcerated  alveolus.  Now,  retraction  of 
the  gums  from  the  teeth,  and  exposure  of  the  bone  of  the  jaw, 
gradually  come  on  until,  in  a  great  many  cases,  the  whole 
dental  arch  projects  into  the  cavity  of  the  mouth  bare  of  peri- 
osteum, and  perfectly  dead.  Numerous  sinuses  usually  form, 
some  opening  into  the  mouth,  and  some  on  the  cutaneous  sur- 
face, and  from  these  escapes  in  large  quantity  a  fetid  pus, 
which,  constantly  flowing  into  the  mouth,  is  one  of  the  most 
offensive  and  distressing  symptoms  of  the  disease;  much  of  it 
must  be  swallowed,  and  can  hardly  fail  to  add  to  the  derange- 
ment of  the  digestive  function,  already  impaired  by  the  progress 
of  the  malady.  As.  the  disease  advances,  involving  a  greater 
and  greater  portion  of  the  jawbone,  the  swelling  of  the  face 
becomes  enormous,  and  the  aspect  of  the  patient,  particularly 
if  both  sides  be  involved,  is  hideous  and  revolting.  Soon  the 
system  begins  to  sympathize,  and  emaciation  and  hectic  are 
slowly  developed.  In  this  respect  a  good  deal  of  difference  is 
observed,  according  to  the  irritability  of  the  patient's  constitu- 
tion, some  being  affected  earlier  in  the  disease  as  well  as  more 
severely.  But  one  point  has  been  distinctly  settled,  viz.,  that 
the  constitutional  symptoms  do  not  show  themselves  until  after 
the  local  disease  has  manifested  itself;  the  poison,  though  acting 
extremely  slowly,  not  appearing  to  influence  the  general  health 
until  it  does  so  through  the  effect  of  the  local  ravages  of  the 
disease.  The  constitution,  however,  once  affected,  rapidly  gives 
way  under  the  constant  suffering  and  exhausting  discharges. 
The  patients  become  pale  and  emaciated,  the  digestive  system 
giving  out  early ;  hectic  fever  is  established,  the  strength  fails, 
and  the  patient  dies  worn  out  by  months  or  even  years  of  pain- 
ful disease. 

In  regard  to  this  point,  of  the  constitutional  impairment 


NECROSIS.  173 

not  depending  on  the  direct  action  of  the  poison  upon  the 
system,  Dr.  Geist  is  very  explicit,  asserting  unequivocally  that 
the  health  of  the  operatives,  not  affected  with  the  local  disease, 
is  as  good  as,  if  not  better  than,  that  of  operatives  in  other  manu- 
factories. He  goes  still  further,  and  states  that,  although  the 
acid  and  irritating  fumes  of  the  phosphorus  are  so  constantly 
inhaled,  no  peculiar  prevalence  of  bronchitis  or  nasal  catarrh 
has  been  noticed  to  occur.  These  facts,  together  with  the 
facts  above  stated,  that  the  disease  never  occurs  in  perfectly 
healthy  mouths,  but  always  requires  a  carious  tooth  or  an 
ulcerated  gum  for  the  starting-point  of  the  inflammation,  seem 
to  show  very  conclusively  that  the  action  of  the  poison  is  en- 
tirely local,  a  view  which  becomes  more  important  when  we 
address  ourselves  to  the  prophylaxis  of  the  complaint. 

The  swelling  about  the  necrosed  jaw  feels  very  hard,  and 
gives  to  the  touch  the  idea  of  an  involucrum  forming  about 
the  dead  bone,  but,  so  far  as  I  know,  no  proper  involucrum  is 
ever  formed.  There  is  found  on  dissection  a  great  thickening 
and  induration  of  the  tissues  about  the  bone,  but  no  ossification 
of  them.  Between  the  separated  periosteum,  however,  and  the 
dead  bone,  there  is  noticed  a  material  which  I  believe  is  not 
found  in  any  other  similar  disease.  It  consists  of  a  grayish 
powder}'  deposit,  which  in  varying  quantities  is  found  to 
adhere  either  to  the  bone  or  to  the  granulating  surface  of  the 
cavity  in  which  it  lies.  Sometimes  this  deposit  adheres 
closely  to  these  granulations,  and,  having  some  consistence, 
forms  a  tolerably  firm  layer,  which  seems  very  much  like  an 
involucrum.  It  will  be  noticed,  however,  that  this  layer  is  not 
a  proper  ossification  of  the  surrounding  tissues,  but  a  mere 
lamina  upon  the  surface  which  can,  with  more  or  less  facility, 
be  peeled  off  from  the  granulations  on  which  it  lies.  On  ex- 
amination this  substance  is  found  to  possess  a  chemical  consti- 
tution and  a  microscopical  structure  which  is  that  of  true  bone, 
but  differing  from  true  bone  in  the  completeness  of  its  develop- 
ment. Yon  Bibra  says :  "  The  Haversian  canals  exhibit  in  part 
a  larger  diameter  than  those  of  normal  bone,  and  are  empty. 
....  They  are  not  parallel  with  the  general  direction  of  the  bone, 
but  are  placed  at  right  angles  to  the  latter ;  they  interlace  with 
one  another,  sometimes  expanding  to  form  sacs,  sometimes 


174  DISEASES   OF  BONE. 

contracting  and  ending  with  open  mouths  on  the  surface. 
These  mouths  are  more  minute  in  the  most  recent  deposit, 
and  appear  larger  in  older  layers.  The  bone-corpuscles  are 
rounded  off  or  angular,  and  their  circumference  is  less  decided; 
during  the  progress  of  the  formation  of  the  deposit  they  are 
very  large,  and  their  contour  proportionally  undefined.  They 
appear  tilled  and  dark-colored.  At  first  they  are  lighter,  and 
they  have  ramifications  like  those  of  normal  bone,  which 
increase  in  number  with  the  age  of  tha  deposit.  .  .  .  The 
matrix  of  the  new  deposit  is  at  first  very  brittle ;  after  the 
deposit  has  been  exposed  to  the  process  of  absorption  it 
shows  a  powdery  appearance,  as  if  sprinkled  with  a  coarse 
powder." 

This  deposit  seems,  therefore,  evidently  to  represent  an 
attempt  on  the  part  of  Nature  to  form  some  new  bone  to  take 
the  place  of  that  which  is  destroyed  ;  but  it  is  also  evident  that 
this  attempt  falls  short  of  the  success  which  it  usually  attains 
in  other  cases  of  necrosis.  Why  this  involucral  effort  should 
be  so  imperfect  and  so  unsuccessful,  it  is  not  easy  to  say,  but 
the  pathological  fact  cannot  be  gainsaid.  The  following  ap- 
pearances were  noted  in  a  case  which  occurred  under  the  care 
of  Dr.  Willard  Parker,  at  the  New  York  Hospital,  and  give, 
perhaps,  a  correct  idea  of  the  usual  pathological  condition,  with 
reference  to  this  pumice-like  deposit :  In  exposing  the  bone 
after  the  first  incisions,  "  it  was  noticed  that  in  some  parts,  par- 
ticularly along  the  base,  the  bone  was  entirely  separated  from 
the  soft  parts  by  a  suppurating  and  granulating  surface,  such 
as  is  ordinarily  seen  between  an  involucrum  and  a  sequestrum, 
while  at  other  points  the  flap  was  peeled  up  from  the  bony 
surface  by  a  process  somewhat  like  that  by  which  the  dura 
mater  is  peeled  from  the  skull-cap,  or  like  that  by  which  the 
periosteum  can  be  peeled  from  the  surface  of  an  inflamed  bone. 
This  raising  of  the  flap  revealed  the  bone,  presenting  two  dif- 
ferent conditions  of  its  surface  :  one  a  smooth,  natural,  evidently 
dead  surface ;  the  other  a  rough,  granular,  and  irregular  surface, 
to  which  the  soft  parts  adhered  as  above  stated,  and  which  did 
not  seem  to  be  dead-bone  tissue,  while  at  the  same  time  it  was 
not  the  usual  vascular-bone  surface  of  an  involucrum.  The 
smooth  dead  bone  was  in  contact  with  pus,  the  other  of  course 


NECROSIS.  175 

was  not.  After  fully  exposing  the  bone  a  chain-saw  was  intro- 
duced near  the  symphysis,  and  the  body  of  the  bone  was  divided 
and  raised  from  its  bed.  As  with  the  outside,  so  with  the 
inner  aspect  of  the  bone,  some  of  it  was  separated  from  the 
soft  parts  by  a  suppurating  surface,  and  some  of  it  adhered 
rather  strongly  to  the  surrounding  parts.  So  strong  was  the 
adhesion  that  at  the  upper  part  of  the  angle  and  neck 
portions  of  the  bony  deposit  flaked  oif  and  were  left  behind 
in  the  bed  from  which  the  bone  was  being  removed.  This  had 
every  appearance  of  being  an  involucrum  at  first  sight,  and  we 
were  in  some  doubt  as  to  whether  it  was  best  to  leave  it.  On 
using  the  handle  of  the  scalpel,  however,  the  soft  parts  were 
easily  peeled  from  it,  and  it  was  enucleated  and  removed.  The 
jawbone  separated  as  usual  at  the  joint  and  came  away  entire, 
and  without  any  considerable  force.  The  removal  of  the  bone 
left  a  bed  which  was  composed  in  part  of  suppurating  and 
granulating  surface,  such  as  is  usually  left  on  the  removal  of 
a  sequestrum,  and  in  part  of  a  whitish,  rough,  vascular  surface, 
looking  not  unlike  the  surface  of  the  dura  mater  recently  peeled 
from  the  skull.  This  seemed  clearly  to  be  the  inner  surface  of 
the  periosteum,  which  had  been  adherent  to  the  rough  deposit 
on  the  surface  of  the  bone,  and  from  which,  beyond  a  doubt, 
the  deposit  had  been  poured  out.  There  was  no  osseous  de- 
posit in  the  periosteum,  and  no  surrounding  ossification,  as 
might  be  expected  around  so  large  a  sequestrum ;  in  short, 
nothing  but  thickened  tissues  represented  the  involucrum.  .  .  . 
The  examination  of  the  jaw  showed  the  whole  bone  to  be 
dead,  but  not  much  altered  from  its  natural  appearance.  On 
the  outer  and  inner  surfaces  of  the  jaw  there  was  an  irregular, 
granular,  stalagmitic  deposit  of  bone,  somewhat  firmly  adhe- 
rent to  the  dead  surface  underneath,  and  looking  better  organ- 
ized and  more  osseous  in  its  appearance  than  the  pumice- 
like  deposit  as  it  is  usually  described.  The  deposit  was  in 
laminae  more  or  less  complete,  and  varied  in  thickness  from  a 
line  to  nearly  half  an  inch.  ...  In  the  main  this  deposit  was 
adherent  to  the  dead  surface  of  the  bone  by  a  sort  of  mechani- 
cal adhesion,  but  in  some  points,  particularly  at  its  edges, 
there  was  a  thin  membrane  between  them,  so  that,  while  the 
whole  was  wet,  some  motion  could  be  made  between  the  bone 


176 


DISEASES   OF  BONE. 


and  its  false  involucral  covering  (Fig.  28).     Under  the  micro- 
scope, thabony  character  of  the  deposit  was  unmistakable." 

It  is  agreed  by  all  the  observers  of  this  disease  that  the 
reparation  after  the  removal  of  the  necrosed  lower  jaw  is  very 
complete,  more  so  perhaps  than  in  any  other  bone  in  the  body. 
In  this  respect,  therefore,  it  would  seem  that  Nature  plans  her 
reparative  work  somewhat  differently  from  the  mode  she  else- 
where adopts.  In  all  ordinary  cases  of  necrosis,  the  periosteum, 


FIG.  23.— <N.  T.  Hospital  Museum.) 

which  is  the  principal  agent  in  forming  the  new  bone,  begins 
its  work  before  a  breach  is  made  in  the  dying  bone,  and  sur- 
rounds the  part  which  is  dead  and  about  to  separate  with  a 
layer  of  n$w  bone,  so  as  to  be  ready  to  meet  the  accident  of 
separation  which  is  about  to  occur ;  and  before  the  sequestrum 
is  removed,  or  even  loose,  enough  involucrum  has  been  formed 
to  supply  the  loss.  This  admirable  provision  seems  to  be  in- 
tended to  prevent  the  limb  from  being  rendered  useless  during 
the  process  of  separation,  by  supplying  a  temporary  support 
which  shall  be  competent  to  maintain  the  functions  of  the  dying 
bone  throughout  the  whole  process. 

In  the  lower  jaw  this  provision  does  not  seem  to  be  made. 
There  is  no  new  bone  deposited  about  the  sequestrum  until  it 
is  got  rid  of;  and  it  is  a  curious  fact  that,  however  long  the 
sequestrum  may  be  allowed  to  remain,  the  formation  of  new 
bone  is  still  withheld  until  the  foreign  body  shall  be  taken  out 


NECROSIS.  177 

of  the  way.  After  this  disturbing  cause  is  removed,  however, 
the  process  of  reparation  is  very  quickly  established,  and  with 
results  which  in  some  instances  are  truly  wonderful.  The 
general  shape  of  the  jaw  is  preserved,  the  angle  is  distinct ;  the 
coronoid  process  can  be  felt,  and  the  muscles  seem  to  have  as 
firm  and  favorable  attachment  as  ever,  while  the  movements 
of  the  jaw  are  entirely  preserved.  An  excellent  illustration 
of  this  regeneration  was  presented  in  one  of  our  New  "i  ork 
Hospital  cases,  which  occurred  in  Dr.  Halsted's  care  in  1856 ; 
the  operation  of  removal  of  one-half  of  the  jaw  was  performed 
in  January,  1857,  and  in  December  following  I  have  noted : 
"  The  half  of  the  jaw  removed  is  replaced  by  firm  bcne,  in 
which  the  angle  of  the  jaw  is  marked,  though  not  quite  as 
acute  as  it  should  be,  and  the  coronoid  process  is  also  clear. 
The  whole  new  bone  is  a  little  smaller  than  the  original,  but  is 
a  remarkable  imitation  of  it.  The  alveolar  border  is  prominent 
into  the  mouth,  and  he  can  chew  upon  it  very  well."  In  an- 
other case,  the  one  already  mentioned,  where,  at  two  distinct 
operations,  the  whole  jaw  was  removed,  I  have  recorded : 
"  Some  months  after  the  operation,"  referring  to  the  last  one, 
"  I  saw  him  and  was  surprised  at  the  small  amount  of  deform- 
ity. An  ingenious  dentist  had  adapted  a  pair  of  plates  with 
teeth  to  the  absent  jaw  with  great  success.  The  plates  rested 
on  a  firm  cicatricial  mass  which  occupied  the  place  of  the  re- 
moved bone,  but  it  was  not  certain  that  any  deposit  of  bony 
matter  had  taken  place."  These  two  cases  present  a  difference 
of  result  which  I  think  has  some  interest  as  bearing  upon  the 
nature  and  significance  of  the  pumice-like  deposit.  In  the 
first  there  was  rapid  and  complete  regeneration  by  bone ;  in 
the  latter  no  bony  deposit  after  the  lapse  of  nearly  a  year. 
Now,  by  referring  to  the  history  of  the  two  cases,  I  find  that, 
in  the  first,  it  is  explicitly  stated  that  at  the  time  of  operation 
there  was  no  bony  invohicrum,  and  no  pumice-like  deposit ; 
while,  in  the  second,  the  pumice-like  deposit  was  in  very 
great  abundance.  In  the  first,  therefore,  we  find  Nature  delay- 
ing all  ossific  action  until  the  sequestrum  was  removed,  and 
then  beginning  it  promptly  and  carrying  it  on  efficiently  to  the 
perfect  regeneration  of  the  lost  bone;  in  the  second  we  have 
a  premature,  imperfect,  and  unsuccessful  attempt  at  ossification 
12 


178  DISEASES   OF   BOXE. 

before  the  sequestrum  is  removed,  in  which  the  disposition  to 
form  a  new  bone  is  frittered  away,  so  that  after  the  operation 
there  seems  no  tendency  left  toward  ossification,  and  a  fibro- 
cartilage  is  all  that  jS'ature  seems  willing  to  undertake.  This  it 
seems  to  me  is  a  fair  view  of  the  significance  of  this  peculiar 
deposit — peculiar,  I  believe,  to  the  phosphorus  cases,  and  I  am 
therefore  disposed  to  regard  it  when  in  great  abundance  as  an 
evil  sign,  and  to  fear  that  its  presence,  before  the  operation, 
indicates  the  absence  of  a  more  healthy  and  useful  ossification 
afterward. 

An  important  practical  question  here  arises:  What  shall  the 
surgeon  do  with  this  layer  of  imperfect  bone-deposit  when  he  en- 
counters it  in  his  operations.  Shall  it  be  removed  or  shall  it  be 
left  ?  If  we  believe  that  it  is  capable  of  taking  part  in  the  re- 
generation which  we  hope  for,  after  the  removal  of  the  jaw, 
then  it  should  be  left.  If,  however,  we  believe  that  it  is  inca- 
pable, both  from  its  nature  and  the  situation  in  which  it  is  found, 
of  taking  on  any  higher  organization,  and  thus  becoming  part 
of  the  new  bone,  then  it  would  be  better  to  remove  it.  With- 
out having  any  facts  positively  bearing  on  this  point,  I  am  in- 
clined to  consider  it  in  the  light  of  an  excrementitious  substance, 
not  available  for  regeneration,  and  therefore  to  be  removed 
whenever  it  adheres  to  the  granulations.  Fortunately,  this 
question  is  most  commonly  solved  for  us  by  the  deposit  adher- 
ing to  the  dead  bone  rather  than  to  the  granulation*,  and  being 
removed  with  the  sequestrum,  to  which  it  is  sometimes  very 


FIG.  29.— (From  Beflevue  Hospital  Museum,  operated  on  by  Dr.  James  E.  Wood.) 

intimately  adherent.     Fig.  29  shows  almost  complete  reforma- 
tion of  lower  jaw  after  phosphorous  necrosis. 


NECROSIS.  179 

The  upper  jawbone  is  also  liable  to  the  ravages  of  the 
phosphorus-disease.  Indeed,  the  statistics  given  by  several  ob- 
servers show  that  it  is  affected  nearly  if  not  quite  as  often  as 
the  lower  jaw.  The  disease  in  the  upper  jaw  presents  no  fea- 
tures different  from  those  already  described,  except  that  all 
observers  agree  that  very  little,  if  any,  bony  regeneration  takes 
place.  The  gap,  left  by  the  fall  of  the  sequestrum,  is  filled 
by  a  firm  fibrous,  or  even  fibro-cartilaginous  substance,  which 
partially  obviates  the  deformity,  and  also  serves  by  its  firmness 
as  a  tolerable  substitute  for  the  absent  bone,  but  usually  no 
ossification  takes  place. 

The  prognosis  of  this  formidable  disease  is  more  favorable 
than  would  at  first  sight  appear.  The  disease  being  so  essen- 
tially local,  and  the  general  system  only  involved  in  sympathy 
with  the  local  disorder,  we  have  usually  a  prompt  recovery 
when  the  local  cause  of  irritation  is  removed.  The  principal 
writers  on  this  subject  mention  very  few  cases  which  proved 
fatal,  and  in  our  New  York  experience  of  the  last  twenty  years 
I  do  not  remember  one  which  destroyed  life.  This  favorable 
prognosis,  after  the  disease  has  accomplished  its  destructive 
mission,  must  not  lead  us  to  expect  to  find  it  tractable  or  man- 
ageable in  its  early  stages.  It  will  rather  be  found  that  when 
once  the  local  action  of  the  poison  has  declared  itself,  no  re- 
moval of  residence,  no  cessation  of  exposure,  no  surgical  treat- 
ment, no  complete  removal  of  the  dead  bone,  will  arrest  the 
progress  of  the  forming  disease,  or  limit  its  ravages  when  fully 
developed.  It  would  rather  seem  that,  when  once  the  local 
poisoning  has  been  so  complete  as  to  produce  the  initial  symp- 
tom of  the  disease,  we  may  count  with  much  confidence  that 
it  will  proceed  through  all  its  stages,  not  much  influenced  by 
the  remedies  cr  regimen  with  which  we  combat  it. 

With  regard  to  treatment,  from  what  has  been  already  said, 
we  can  hope  for  but  little  in  the  direct  control  of  the  disease, 
but  much  can  be  done  which  shall  mitigate  suffering,  and  per- 
haps shorten  its  period.  And  first,  as  a  matter  of  course, 
removal  from  exposure  to  the  fatal  fumes  must  be  insisted 
on.  All  favorable  hygienic  conditions  must  be  secured  as  far 
as  circumstances  will  permit,  and,  above  all,  cleanliness  of  the 
diseased  parts  by  frequent  ablutions,  so  that  the  discharges  shall 


180  DISEASES   OF  BONE. 

be  kept  from  becoming  decomposed,  and  in  that  state  finding 
their  way  into  the  stomach.  For  this  purpose,  warm  water 
freely  and  frequently  used  is  the  most  efficient  of  all  detergents ; 
but,  owing  to  the  soreness  of  the  parts  and  the  difficulty  of 
motion,  both  of  the  tongue  and  the  jaws,  patients  are  unwilling 
or  careless  about  its  use ;  and  it  is  better,  particularly  with  the 
least  intelligent,  to  make  some  formal  prescription  whioh  will 
be  much  more  likely  to  receive  attention.  A  weak  solution  of 
tincture  of  myrrh,  perhaps  combined  with  a  few  drops  of  Labar- 
raque's  solution  of  chloride  of  soda,  makes  an  excellent  and  not 
disagreeable  wash,  which  gently  stimulates  the  granulating  sur- 
faces while  it  cleanses  the  mouth.  Attention  must  also  be  paid 
to  the  diet  of  the  patients.  They  cannot  chew,  and  the  food 
must  therefore  be  soft.  The  condition  of  the  mouth  prevents 
them  from  enjoying  the  taste  of  what  they  eat,  and  this,  with 
the  want  of  appetite,  will  lead  them  to  neglect  themselves  in 
this  important  particular.  It  is  therefore  the  surgeon's  duty 
to  see  that  they  have  the  right  food,  and  that  they  partake  of 
it  in  proper  quantities  and  at  proper  intervals.  Milk  and 
meat-soups,  with  eggs,  will  form  the  most  convenient  and 
nourishing  forms  of  diet,  varying  the  form  to  suit  the  changing 
taste.  Tonics,  as  iron  and  quinine,  and  bitters,  will  be  appro- 
priate as  medicines,  while,  in  many  cases,  stimulants  will  be 
required,  either  in  the  milder  form  of  ale  or  porter,  or  in  the 
more  decided  shape  of  wine,  whiskey,  or  brandy.  This  invigo- 
rating regimen  is  called  for  in  almost  every  case,  in  the  later 
and  more  prolonged  period  after  the  first  abscesses  have  broken, 
and  while  the  profuse  and  fetid  discharge  is  creating  a  constant 
drain  upon  the  patient's  strength. 

The  main  question,  however,  remains  as  to  local  manage- 
ment ;  and  here  two  views  prevail :  One  party,  fascinated 
perhaps  by  the  conservative  suh-periosteal  surgery  of  M.  Oilier, 
is  led  to  devote  a  great  deal  of  attention  to  the  condition  of 
the  periosteum  surrounding  the  dead  bone,  and  by  various 
blunt  instruments  thrust  in  between  the  membrane  and  the 
bone  to  secure  its  separation  and  perhaps  to  hasten  the  process. 
These  manipulations  are  kept  up  day  after  day,  giving  the 
patient  a  great  deal  of  pain,  wounding  and  bruising  the  tender 
surfaces,  and  exciting  sometimes  not  a  little  consecutive  inflain- 


NECROSIS.  181 

mation.  This  preliminary  treatment,  as  it  is  regarded,  is  in- 
tended to  prepare  the  patient  for  the  final  separation  of  the 
bone,  when  the  time  for  operation  comes,  so  that  the  sequestrum 
shall  come  away  easily,  and  the  periosteum  shall  not  be  involved 
with  it.  I  cannot  help  believing  that  this  is  bad  surgery,  and 
I  think  so  for  two  reasons :  First,  I  do  not  believe  that  with 
any  instrument,  be  it  ever  so  flexile  and  so  delicate,  we  can 
follow  the  line  of  separation  in  a  bone  so  irregular  as  the  lower 
Or  upper  jaw,  nor  can  we  accurately  appreciate  the  extent  to 
which  the  separation  is  going  to  take  place.  We  constantly 
run  the  risk,  therefore,  in  trying  thus  to  interfere  with  the 
process,  of  wandering  from  the  space  which  Nature  intends  to 
leave  between  the  periosteum  and  the  bone,  and  also  of  going 
farther  in  the  separation  than  Nature  proposes  to  go.  Secondly, 
we  gain  nothing  by  such  a  course,  for  Nature  will  certainly  and 
accurately  limit  the  disease,  and  the  space  between  the  dead 
and  living  will  be  just  as  perfect  and  just  as  distinct  as  we  can 
make  it  with  our  instruments.  The  operations  are  useless  for 
the  end  proposed,  and  injurious  in  their  effect  upon  the  natural 
progress  of  the  disease.  Their  principle,  therefore,  as  well  as 
their  practice,  is  in  my  judgment  equally  unsound. 

I  would  recommend,  therefore,  no  interference  with  the 
disease,  except  so  far  as  concerns  letting  out  matter  as  early  and 
freely  as  may  be,  until  the  time  shall  come  when  the  removal 
of  the  dead  mass  may  be  wisely  undertaken.  And  here  I  fear 
surgeons  are  too  apt  to  err  on  the  side  of  haste.  The  disease 
is  so  distressing,  its  features  so  offensive,  both  to  patients  and 
friends,  its  progress  is  so  unmarked  and  so  slow,  that  the  natu- 
ral tendency  is  to  operate  as  soon  as  possible  in  order  to  be  rid 
of  so  much  suffering  and  annoyance.  It  is  extremely  desirable 
that  no  operation  should  be  undertaken  until  separation  be  so 
complete  that  the  dead  can  easily  be  removed  from  the  living 
parts.  This  remark,  however,  has  reference  more  to  the  con- 
nections of  the  bone  with  its  articulating  cavity,  and  with  the 
soft  parts  which  environ  it,  than  to  any  separation  which  may 
be  looked  for  in  the  continuity  of  the  bone.  The  ligamentous 
and  tendinous  attachments  of  the  bone  at  its  articulation  will 
in  the  course  of  a  few  weeks  or  months  become  so  loosened 
that,  if  the  whole  articular  extremity  be  dead,  as  is  usually  the 


182  DISEASES  OF  BONE. 

case,  it  cau  be  torn  out  of  its  bed  by  a  sort  of  twisting  motion, 
by  the  exercise  of  a  moderate  force.  The  periosteum  will 
separate  from  its  sides  in  perhaps  a  shorter  period,  so  that  every 
part  is  detachable  excepting  at  the  point  where  the  diseased 
side  is  continuous  with  the  sound.  Here,  Nature  seems  again 
to  fail  in  accomplishing  her  usual  task.  Separation  either  does 
not  take  place  at  all,  or  takes  place  so  slowly  and  so  imperfectly, 
that  we  cannot  wait  for  its  completion,  and  in  every  case  which 
I  have  seen  it  has  been  necessary  to  divide  the  bone  at  or  near 
the  symphysis,  so  as  to  get  away  what  was  at  all  other  points 
easily  enucleable.  This  slowness  of  separation  seems  to  me 
characteristic  of  the  jawbones  in  all  their  necroses,  from  what- 
ever cause,  where  the  dead  part  embraces  any  thing  beyond  the 
alveolar  margins.  I  have  marked  the  same  indisposition  to 
separation  in  maxillary  necrosis  after  fracture,  as  well  as  in  the 
necrosis  which  occurs  from  excessive  salivation.  In  cancrum 
oris  even  in  very  young  children  the  process  of  bone  separation 
is  marked  by  the  same  sluggishness  and  delay.  This  general 
course  would  lead  to  the  belief  that  it  belonged  to  the  bone 
itself  rather  than  depended  on  any  particular  condition  of  dis- 
ease, to  undertake  the  duty  of  separation  slowly  and  reluc- 
tantly. 

The  operation  for  the  removal  of  the  sequestrum  will  be 
modified  according  to  the  extent  of  the  disease.  If  one  entire 
half,  or  if  the  whole  bone  be  dead,  then  it  is  necessary  to  make 
a  free  incision  along  the  base  of  the  jaw,  from  above  the  angle 
to  near  the  symphysis,  and,  cutting  directly  through  the  thick- 
ened tissues  which  represent  the  involucrum,  expose  the  seques- 
trum freely.  The  jaw  should  next  be  divided  at  or  near  the 
symphysis  by  a  chain-saw,  by  which  procedure  the  half  we  wish 
to  remove  becomes  manageable.  By  now  carefully  removing 
the  adherent  tissues  from  all  sides,  and  following  this  dissection 
up  to  the  articular  condyle,  we  are  soon  able,  by  a  sort  of  twist- 
ing, tearing  movement,  to  drag  the  whole  mass  from  all  its 
remaining  attachments,  and  it  usually  comes  away  entire.  If 
both  sides  are  affected,  the  operation  is  to  be  repeated  on  the 
remaining  half.  If,  as  is  very  often  the  case,  the  condyle  is 
still  living  and  sound,  then  no  force  we  can  safely  use  will 
bring  it  out  of  its  socket,  and  the  operation  should  be  completed 


NECROSIS.  183 

by  cutting  or  sawing  off  the  bone  beyond  the  diseased  point, 
making  sure  to  cut  through  healthy,  living  bone-tissue,  else 
some  of  the  sequestrum  would  be  left  behind.  Yery  little 
cutting  is  required  after  making  the  first  incision,  and  there 
is  rarely  any  considerable  haemorrhage.  After  making  sure 
that  all  fragments  or  flakes  of  bone  are  removed,  nothing  re- 
mains but  to  bring  the  wound  carefully  together  with  fine 
sutures  and  dress  it  lightly.  Sometimes  it  is  well  to  dress  the 
cavity  with  lint  from  the  inside  to  keep  it  in  better  shape  while 
it  is  granulating.  This  is  not  always  necessary,  however,  as 
the  firmness  of  the  consolidated  tissues  generally  keeps  the 
outline  of  the  jaw  tolerably  supported.  The  wound  generally 
behaves  extremely  well,  healing  rapidly,  and  without  accident 
or  complications.  If  the  disease  be  limited  to  a  portion  of  the 
body  of  the  jaw,  then  an  incision  will  have  to  be  made  through 
sound,  living  bone  on  both  sides  of  the  dead  piece,  in  order  to 
remove  it.  Sometimes  in  these  more  moderate  cases,  and  even 
in  the  most  extensive,  the  operation  has  been  practised  through 
the  mouth  without  external  incision.  This  is  of  course  a  more 
tedious  process,  but  wherever  it  can  be  done  I  think  it  should 
be  attempted,  particularly  in  females,  to  save  the  deformity 
of  so  extensive  a  scar. 

"With  regard  to  recurrence  after  removal,  it  is  not  very  un- 
frequent,  even  if  the  patient  be  not  again  exposed  to  the  vapors 
of  phosphorus,  for  the  disease  to  extend  beyond  the  limits  of 
the  operation,  or  to  show  itself  in  some  new  part  either  of  the 
upper  or  lower  jawbones,  and  to  require  a  second  operation 
perhaps  as  formidable  as  the  first.  This,  however,  must  be,  if 
the  first  operation  be  not  too  hastily  performed,  an  unusual 
occurrence. 

The  upper  jaw  presents  some  features  in  which  it  differs 
from  the  lower  jaw  in  this  disease.  It  is  attacked  nearly  as 
frequently  as  the  lower  jaw,  but  generally  to  a  more  limited 
extent.  The  destruction  is  mostly  confined  to  the  alveolar  arch, 
in  bad  cases,  however,  involving  the  bone  more  extensively. 
There  is  but  little  of  the  immense  brawny  swelling  which 
represents  the  involucrum  in  the  lower  jaw,  and  there  seems 
to  be  a  greater  readiness  to  effect  the  separation  of  the  seques- 
trum. The  operation  is  usually  simpler,  performed  more  easily 


184  DISEASES  OF   BONE. 

through  the  mouth  than  is  the  case  in  the  lower  jaw,  and  con- 
sists mainly  in  freeing  mucous  membrane  so  as  to  permit  of 
the  pulling  out  of  the  loosened  dead  mass.  It  is  also  to  be 
noticed  that  no  reparation  by  bone  takes  place  in  the  upper 
jaw,  and  scarcely  any  compensating  fibrous  deposit  fills  up  the 
void.  The  deformity  is  very  great,  therefore,  and  it  is  fortunate 
that  the  art  of  the  dentist  enables  him  to  remedy,  in  so  satis- 
factory a  manner,  both  the  deformity  and  the  disability. 

5.  Necrosis  after  Fractures. — Nothing  is  more  common 
than  to  find  the  ends  of  the  broken  bone,  in  compound  fractures, 
in  a  state  of  necrosis.  Long  exposed  to  air,  in  contact  with 
pus,  and  with  the  periosteum  perhaps  stripped  up  to  a  certain 
extent  by  the  original  injury,  it  is  not  surprising  that  the  most 
exposed  and  the  most  injured  bone-fibres  should  be  liable  to 
die.  Accordingly,  we  find  it  rather  the  exception,  in  compound 
fractures  in  adults,  that  the  wound  heals  soundly  without  any 
exfoliation  of  bone.  Most  commonly  the  broken  end  sheds,  at 
the  end  of  two  or  more  months,  a  small  section  of  bone,  which 
finds  its  way  to  the  surface,  and  is  easily  removed  without  its 
presence  having  in  any  material  degree  interfered  with  the 
prompt  and  complete  uniting  of  the  fracture.  This  necrosis, 
however,  may  be  more  extensive,  more  of  the  bone  may  be 
involved,  and  thus  we  have  sometimes  one  or  more  con- 
siderable sequestra  lying  between  the  ends  of  the  bone, 
interfering  with  their  union  and  keeping  up  an  excessive 
and  an  unnecessary  suppuration.  In  these  cases  the  earlier 
stages  of  the  fracture  may  not  be  characterized  by  any  unfa- 
vorable symptoms.  The  wounds  may  go  on  favorably  toward 
healing,  and  union  may  occur  of  the  broken  bone;  but  the 
wounds  do  not  actually  heal,  and  solid  union  is  delayed.  Fistu- 
lous  openings  lead  down  to  bare,  dead  bone,  and  the  whole 
region  of  the  fracture  presents  an  unusual  degree  of  thickening 
and  induration.  This  state  of  things  may  continue  indefinitely  ; 
and,  indeed,  the  patient  may  be  walking  about  on  his  limb, 
month  after  month,  and  yet  no  bone  comes  away,  and  the 
wound  does  not  heal.  Or  it  may  happen  that  union  is  im- 
perfect, or  altogether  prevented  by  the  presence  of  some  more 
important  sequestrum  between  the  fragments  which  have  other- 
wise every  disposition  toward  healthful  repair.  In  one  case, 


NECROSIS.  185 

union  of  a  broken  femur  had  been  delayed  for  many  months 
by  a  fragment  of  dead  bone  lying  crosswise  between  the  ends ; 
and  a  feeble  bridge  of  delicate  bone  is  the  only  attempt  which 
the  specimen  shows  toward  the  union  of  the  fragments  sepa- 
rated, by  this  foreign  body,  nearly  an  inch  from  one  another. 

This  condition  of  things  is  brought  about  in  one  of  two 
ways.  Either  the  ends  of  the  fragments  die  from  exposure  in 
the  wound,  or  else  original  fragments,  separated  more  or  less 
completely  from  the  shaft,  die  from  the  same  exposure  soon 
after  the  accident.  The  difference  can  be  easily  recognized 
in  examining  the  sequestrum,  which,  in  the  former  case, 
will  always  present  the  irregular  worm-eaten  surface,  which 
shows  where  it  has  been  detached  by  a  process  of  absorption ; 
while  the  latter  shows,  on  all  sides,  the  evidences  of  original 
fractured  surfaces. 

Fig.  30  shows  the  ends  of  each  fragment  in  a  compound 
fracture  of  tibia  in  a  state  of  necrosis,  with  the  line  of  separa- 
tion well  marked,  at  a  little  less  than  an  inch  from  the  fracture. 
Both  fragments  are  affected  to  about  the  same  extent,  and  the 
deposition  of  callus  from  the  living  bone,  above  and  below  the 
line  of  separation,  is  hardly  begun,  though  several  weeks  had 
elapsed  since  the  injury.  This  sequestrum,  when  detached, 
would  have  presented  one  surface  of  original  fracture,  and  one 
where  it  was  irregular  from  detachment  by  absorption,  showing 
that  it  was  not  an  original  fragment  which  had  died,  but  a 
piece  separated  by  Nature  long  after  the  injury. 

Fig.  31  shows  the  appearance  of  a  dead,  original  fragment 
in  situ.  It  was  taken  from  a  man,  nineteen  years  old,  who 
suffered  a  compound  fracture  from  a  fall.  He  struggled  for  six 
months  to  repair  his  injury,  but  at  the  end  of  that  time  no 
union  had  occurred,  and  an  operation  was  performed  by  cutting 
down  at  the  seat  of  fracture  and  removing  the  large  sequestrum 
which  lay  between  the  broken  extremities  of  the  bone.  Exami- 
nation showed  this  to  be  an  original  fragment  separated  at  the 
time  of  the  accident,  and  dying  in  consequence  of  its  detach- 
ment from  the  surrounding  living  tissues.  It  lay  almost  trans- 
versely between  the  bones,  and,  although  the  young  man  lin- 
gered four  months  after  the  removal  of  the  dead  piece,  yet 
scarce  any  union  was  accomplished,  a  feeble  bridge  of  bone  at 


186 


DISEASES   OF   BONE. 


the  posterior  part  of  the  space  being  all  that  Nature  could 
accomplish.  In  the  preparation  of  the  specimen  the  fragment 
was  replaced  in  its  original  position,  and  so  appears  in  the 
woodcut. 


FIQ.  30.— <N.  Y.  Hospital  Museum.) 


FIG.  31.— (N.  T.  Hospital  Museum.) 


This  death  of  detached  fragments  is  not  uncommon  in  com- 
pound, but  I  think  it  must  be  exceedingly  rare  in  simple 
fractures.  The  following  is  an  interesting  example :  A  bov 

o  i  • 

entered  the  Xew  York  Hospital  in  October,  1854,  with  a  simple 
fracture  of  both  thighs  and  a  fracture  of  the  lower  jaw.  For 
about  three  weeks  nothing  unfavorable  presented  itself;  but  at 
the  end  of  that  time  it  was  observed  that  the  right  thigh  was  a 
good  deal  swollen  at  the  seat  of  fracture,  and  he  had  been  com- 
plaining of  pain  and  tenderness  about  it  for  several  days.  In 


NECROSIS. 


187 


about  a  week  suppuration  was  evident,  and  a  large  quantity  of 
matter  was  evacuated  by  incision.  The  abscess  did  not  heal, 
the  union  of  the  fracture  did  not  take  place,  arid  finally  dead 
bone  could  be  discovered  by  the  probe,  while  a  great  deal  of 
solid  thickening  surrounded  the  seat  of  fracture.  Several 
months  afterward  an  operation  was  performed  by  cutting  down 
upon  the  fracture  and  removing  the  dead  portion  of  bone.  It 
was  found  to  be  a  fragment,  embracing  nearly  the  whole  thick- 
ness of  the  femur,  which  had  been  originally  separated  at  the 
time  of  the  accident  and  had  died  entire.  Its  surfaces  showed 
very  distinctly  that  it  had  not  been  separated  by  any  process  of 
absorption.  The  patient  ultimately  got  a  good  limb.  Whether 
in  this  case  death  of  the  fragment  took  place  from  complete 
separation,  and  thus  produced  the  abscess,  or 
whether  the  suppuration  caused  the  death  of  the 
partially-detached  fragment,  I  never  was  able 
to  determine,  but  it  is  so  extremely  rare  that 
suppuration  takes  place  in  a  simple  fracture 
that  I  incline  to  the  first  explanation. 

Again,  there  are  some  cases  in  which  necro- 
sis after  fracture  involves  larger  portions  of  the 
bone  than  are  either  exposed  in  the  wound,  or 
than  can  be  supposed  to  be  affected  by  the  in- 
jury. In  these  cases  it  must  be  supposed  either 
that  an  acute  osteitis  has  spread  from  the  point 
of  injury,  or  that  a  suppuration  has  detached 
the  periosteum  from  the  bone,  in  either  case 
extending  the  area  of  the  disease  till  it  some- 
times is  found  to  involve  the  greater  part  of 
the  shaft  (Fig.  32). 

The  indications  of  treatment  are  here  very 
clear.  After  allowing  full  time,  say  an  average 
of  three  months,  for  the  spontaneous  detach- 
ment of  the  sequestrum,  it  is  best  to  proceed 
at  once  to  an  operation  for  its  removal.  A 
natural  unwillingness  is  felt  to  interfere  with 
the  processes  of  union  of  the  fracture  by  a  serious  and  disturb- 
ing operation,  but  this  unwillingness  will  cease  if  we  reflect, 
first,  that  the  dead  bone  is  itself  an  obstacle  to  good  union  ;  and, 


FIG.  82.— (N.  Y.  Hospi- 
tal Museum.) 


188  DISEASES  OF  BONE. 

secondly,  that  in  old  compound  fractures  the  effect  of  free  inci- 
sions, and  free  manipulation  with  the  fragments,  is  generally 
to  improve  the  sluggish  action  of  the  parts,  and  to  insure 
a  more  rapid  and  solid  union.  So  true  is  this,  that  in  one 
or  two  doubtful  cases,  where  I  have  cut  down  without  find- 
ing any  dead  bone,  I  have  found  the  condition  of  the  frac- 
ture improve  so  much,  apparently  from  the  stimulus  of  the 
operation,  that  I  have  had  no  reason  to  regret  my  mistaken 
diagnosis.  Of  course  no  unnecessary  violence  should  be  done 
which  might  break  up  union  already  secured,  and  no  more 
bone-substance  should  be  removed  than  is  absolutely  necessary 
to  insure  access  to  the  sequestrum.  In  one  case  recently,  in 
the  thigh,  I  was  obliged  to  break  up  the  union  in  order  to  get 
at  the  dead  piece  which  was  wedged  between  the  overlapping 
fragments.  No  evil  consequences  ensued  in  this  case,  however, 
and  I  have  got  an  excellent  thigh. 

Fracture  may  occur  in  a  bone  which  is  the  subject  of  necro- 
sis, and  may  involve  the  involucrum  either  in  its  forming  or  its 
completed  condition.  The  fracture 'of  the  involucrum  during 
its  forming  stage  is  probably  rare,  because,  though  it  is  the 
weakest  period  of  the  new  formation,  yet  the  limb  is  usually  so 
little  moved,  in  the  earlier  and  inflammatory  stages  of  the  dis- 
ease, that  it  is  not  very  liable  to  be  injured.  By  the  time  the 
patient  is  able  to  use  the  limb  with  comfort,  Xature  has  usually 
accomplished  the  solidification  of  the  new  bone.  After  that 
period  I  suppose  the  bone  is  usually  less  liable  to  fracture 
through  the  involucrum  than  elsewhere,  on  account  of  the 
abundant  material  provided  for  securing  the  strength  of  the 
bone  at  the  point  of  disease.  The  accident  does,  however, 
occasionally  occur,  and  may  happen  either  before  the  removal 
of  the  sequestrum  or  at  some  period  after  such  removal.  The 
following  case  illustrates  the  fracture  of  the  involucrum  while 
the  sequestrum  still  remains  imprisoned : 

Mr.  C.,  aged  about  thirty,  a  strong  and  otherwise  healthy 
butcher,  had  been  under  the  care  of  my  friend  Dr.  James 
Fergusson,  with  necrosis  of  the  left  os  brachii.  A  large  seques- 
trum was  lying  loose  in  a  cavity  in  the  middle  portion  of  the 
shaft,  and  was  ready  for  an  operation,  which  Dr.  Fergusson  had 
repeatedly  recommended  him  to  have  performed.  Mr.  C., 


NECROSIS.  189 

however,  had  postponed  the  operation  from  time  to  time,  as  his 
arm  gave  him  but  slight  inconvenience,  and  interfered  but  little 
with  the  prosecution  of  his  business.  On  one  occasion,  in  try- 
ing to  lift  a  heavy  piece  of  meat  to  hang  it  on  a  high  hook,  he 
felt  a  sudden  snap  in  the  centre  of  his  diseased  arm,  which  fell 
helpless  to  his  side.  The  bone  had  broken  directly  through  the 
involucrum,  and  had  torn  its  way  through  the  integuments, 
making  a  bad  compound  fracture.  Between  the  fragments,  in 
a  large  cavity  which  was  now  quite  exposed,  could  be  seen  and 
felt  the  sequestrum,  which  itself  had  not  suffered  fracture.  It 
was  in  this  condition  of  things  I  saw  him  in  consultation.  The 
first  thing  to  be  done  was  evidently  to  remove  the  foreign  body. 
This  was  easily  done  by  rotating  the  arm  so  as  to  separate  the 
fragments  and  thus  more  fully  expose  the  sequestrum.  Then, 
by  a  few  touches  of  the  chisel,  it  was  released  from  its  bed  and 
removed.  This  reduced  the  injury  to  a  mere  compound  frac- 
ture without  complication.  The  displacement  was  easily  re- 
duced and  easily  retained,  the  broad,  broken  surfaces  of  the 
involucrum  fitting  accurately  into  one  another,  and  mutually 
supporting  each  other.  The  limb  was  placed  in  an  angular  tin 
splint,  and  retained  in  it  during  all  the  time  of  its  union.  The 
cure  went  on  as  rapidly  as  I  ever  saw  in  any  compound  fracture, 
though  the  large  involucral  cavity  was  somewhat  slow  in  filling 
up.  The  wound,  however,  finally  healed,  and  he  had  a  per- 
fectly sound  and  strong  arm.  It  is  at  least  eighteen  years  since 
the  fracture,  and  Mr.  C.  has  had  no  trouble  with  it  since.  Two 
other  cases  of  a  similar  character,  and  equally  fortunate  issue, 
have  occurred  to  me  in  the  ISTew  York  Hospital. 

The  next  case  is  one  in  which  fracture  took  place  several 
months  after  the  sequestrum  was  removed,  and  is  very  interest- 
ing in  showing  some  of  the  remote  effects  of  such  an  injury,  as 
well  as  some  of  the  serious  emergencies  that  may  arise  in  en- 
deavoring to  obviate  them : 

Mr.  L.,  a  merchant  in  New  York,  came  Tinder  my  care  in 
the  spring  of  1870,  for  the  relief  of  a  deformity  of  his  left  femur, 
of  which  he  gave  the  following  history:  At  eight  years  of  age 
he  had  an  attack,  resembling  acute  rheumatism,  of  the  lower 
part  of  the  left  thigh.  For  about  a  year  the  limb  continued 
very  painful,  and  finally  an  abscess  appeared  under  the  knee, 


190  DISEASES   OF  BONE. 

and  was  opened.  Some  time  after  this  a  fistulous  opening  ap- 
peared on  the  outside  of  the  thigh,  near  the  knee,  and  then  a 
second  fistula  formed  on  the  inside.  These  openings  continued 
to  discharge,  and  several  small  pieces  of  bone  came  away  at 
intervals,  until  he  was  about  eighteen  years  old,  when  he  pulled 
away  a  sequestrum  as  large  as  his  finger.  Soon  after  this  all 
the  wounds  healed.  About  eighteen  months  after,  he  was 
thrown  from  his  horse,  and  sustained  a  fracture  of  the  thigh 
directly  at  the  point  which  had  been  the  seat  of  the  necrosis. 
The  fracture  was  treated  with  a  long  splint,  which  was  kept  on 
for  eight  weeks.  During  the  first  few  days  he  was  allowed  to 
move  himself  about  in  the  bed,  but  during  the  rest  of  the 
treatment  he  was  kept  quiet.  When  he  left  his  bed  the  limb 
was  quite  straight,  but  afterward  gradually  became  bent  out- 
ward, the  deformity  increasing  slowly  up  to  the  present  time. 
Four  years  ago  another  abscess  appeared  on  the  inside  of  the 
thigh,  about  a  hand's  breadth  above  the  knee-joint,  followed  by 
a  fistula,  which  has  ever  since  continued  to  discharge.  During 
the  last  month  the  discharge  has  increased.  Latterly  there  has 
been  some  inflammatory  pain  about  the  knee-joint.  Thinks 
that  the  sensibility  of  the  left  foot  and  ankle  has  been  less 
than  that  of  the  right.  His  present  condition  is  that  of  vigorous 
health,  though  he  thinks  it  has  failed  a  little  in  the  last  few 
months.  The  thigh  is  bent  at  the  junction  of  the  lower  and 
middle  third,  or  a  little  below  this  point,  so  as  to  make  a  great 
prominence  outward,  throwing  the  leg  out,  so  as  to  make  very 
serious  deformity,  and  to  give  him  a  most  ungainly  walk.  The 
limb,  however,  is  strong,  and  with  a  cane  he  can  walk  well. 
The  fistula  .discharges  quite  freely,  though  the  probe  does  not 
come  in  contact  with  dead  bone.  The  knee-joint  is  quite  rigid, 
and  gradually  becoming  more  and  more  so.  It  has  on  several 
occasions  been  swollen  and  painful,  so  as.  for  a  few  days  at  a 
time,  to  prevent  his  going  down  to  his  business. 

On  the  21st  of  May,  1870,  assisted  by  Dr.  George  A.  Peters, 
Dr.  Chamberlain,  and  Dr.  Del  afield,  I  undertook  an  operation 
for  the  relief  of  the  deformity,  and  for  the  removal  of  any 
sequestrum  I  might  find.  An  incision  was  made,  beginning  at 
the  fistula  and  extending  upward,  by  which  the  surface  of  the 
bone  was  reached,  and,  after  much  labor  with  the  thickened 


NECROSIS.  191 

periosteum,  and  the  consolidated  tissues  around  it,  was  exposed. 
No  dead  bone  was  seen  or  felt,  nor  could  we  find  any  cavity 
which  might  contain  one.  Attempts  were  then  made  to  break 
the  femur,  but  this  could  not  be  accomplished  until,  by  the 
chisel,  the  bone  had  been  cut  nearly  through.  After  fracturing 
the  bone,  and  cutting  and  stretching  a  few  resisting  aponeu- 
rotic  fibres  on  the  inside  of  the  limb,  the  deformity  was  easily 
and  completely  obviated.  The  two  portions  of  the  femur  were 
nearly  in  a  straight  line,  and  the  limb  did  not  appear  shorter 
than  its  fellow.  While  pressing  the  limb  inward,  so  as  to 
straighten  it  more  perfectly,  a  sudden  gush  of  arterial  blood 
from  the  wound  announced  the  rupture  of  a  large  artery,  which, 
from  the  situation  and  the  size  of  the  stream,  we  could  not 
doubt  was  the  popliteal.  Pressure  was  instantly  made  with 
the  finger  on  the  iliac,  and  by  sponges  in  the  wound,  and  the 
flow  was  stopped,  but  not  till  much  blood  had  been  lost. 
The  artery  was  then  sought  for  in  the  wound,  and,  after  infinite 
trouble  and  labor,  what  were  supposed  to  be  the  two  ends  of 
the  lacerated  artery  were  secured  by  a  ligature,  and  the  haem- 
orrhage ceased.  The  limb  was  put  up  with  the  extension 
apparatus,  with  weight  and  pulley,  in  the  usual  manner.  The 
length  and  shape  of  the  limb  were  entirely  satisfactory. 

He  came  out  from  the  influence  of  the  ether,  and  all  seemed 
so  well  tlmt  I  left  him  in  charge  of  Dr.  Delafield,  taking  the  pre- 
caution to  have  a  tourniquet  left  loosely  round  the  limb.  I  had 
not  arrived  at  my  house  more  than  a  few  minutes  when  I  was 
summoned  with  the  message  that  he  was  bleeding  severely.  I 
took  Dr.  Gnrdon  Buck  and  Dr.  Peters  with  me,  in  consultation, 
and  on  our  arrival  we  found  that  the  ligatures,  one  or  both,  had 
slipped  off,  or  that  they  had  not,  after  all  our  care,  been  fairly 
placed  on  the  vessel ;  for  the  gush  of  blood  had  been  as  great  and 
as  rapid  as  at  the  first,  and  the  patient  was  in  a  very  alarming 
state  of  prostration.  The  question  was  between  ligature  of  the 
femoral  artery  and  amputation.  Inasmuch  as  the  ligature  could 
not  add  materially  to  the  danger  of  gangrene,  the  arterial  current 
being  already  interrupted  by  the  laceration,  we  concluded  to  tie 
the  artery  low  down  in  Scarpa's  triangle,  and  take  what  chance 
there  was  for  saving  the  limb.  This  was  accordingly  done. 

From  the  great  loss  of  blood,  the  prolonged  anaesthesia  of 


192  DISEASES  OF  BONE. 

several  hours,  and  the  shock  of  three  severe  operations,  Mr.  L. 
was  very  much  prostrated,  and  for  several  days  rallied  very 
slowly  under  careful  tonic  and  stimulant  regimen,  with  the 
cautious  administration  of  the  best  food  which  his  stomach 
would  bear.  During  this  critical  term,  however,  while  his 
capillary  circulation  was  so  extremely  enfeebled,  the  injured 
limb  was  struggling  for  life.  All  pressure  from  the  bandages 
was  removed,  and,  as  the  surface  was  white  and  cold,  moderate 
artificial  heat  was  applied  by  sand-bags  placed  around  and  at 
some  distance  from  the  limb.  The  result  remained  several  days 
in  suspense,  but  gradually  the  circulation  failed  more  and  more 
completely,  until  June  1st,  when  the  evidences  of  mortification 
were  so  distinct  that  amputation  was  performed  about  the 
middle  of  the  thigh.  The  stump  did  well  in  every  particular, 
and  he  rapidly  regained  his  health  and  strength. 

A  careful  dissection  of  the  amputated  limb  was  made,  and 
the  popliteal  artery  found  to  be  lacerated  just  opposite  the 
fracture  which  I  had  made,  the  ends  of  the  torn  vessel  being 
widely  separated ;  no  trace  of  the  original  ligatures  could  be 
found.  The  nerve  was  intact,  as  was  also  the  vein.  All  these 
were  very  closely  bound  to  the  bone,  apparently  by  the  con- 
densation of  the  surrounding  areolar  tissue,  from  the  inflam- 
matory action  which  had  for  so  many  years  been  going  on  in 
the  neighborhood.  The  edges  of  the  fracture  were  not  particu- 
larly sharp,  and  it  seemed  to  me  that  the  explanation  of  the 
accident  to  the  artery  was,  that  it  was  stretched  by  the  straight- 
ening of  the  bones  in  such  a  way  as  to  be  pressed  upon  directly 
by  the  ends  of  the  fragments,  and,  being  incorporated  with  the 
surrounding  consolidated  tissues,  it  had  lost  its  elasticity  and 
its  power  of  eluding  pressure,  and  it  gave  way.  The  knee-joint 
showed  traces  of  recent  inflammation,  and  was  extremely  rigid. 
The  amputated  end  of  the  femur,  after  maceration,  was  found 
to  be  thicker,  harder,  and  heavier  than  in  a  natural  state.  This 
was  most  noticeable  immediately  about  the  point  of  old  frac- 
ture, where  the  bone  was  thickened  by  involucral  action  and 
deposition  of  callus  (Fig.  33).  The  outline  of  the  old  fracture 
could  be  distinctly  traced.  About  an  inch  below  the  point  at 
which  I  had  broken  the  bone,  a  small  opening  of  the  size  of  a 
pea  led  into  a  cavity  in  the  bone  about  large  enough  to  contain 


NECROSIS. 


193 


3  ij  of  fluid.  This  cavity  extended  up  to,  and  was  opened 
partly  by  the  chisel,  and  partly  by  the  fracture,  which  extended 
nearly  transversely  through  the  bone,  and  was  without  splinters. 
The  bone  had  separated  through  the  thickest  part  of  the  old 


FIG.  33.— (N.  T.  Hospital  Museum.) 


FIG.  M.— (From  Bfflroth.) 


union,  where  the  tissue  was  firm,  porous  bone,  but  nowhere 
cancellous.  The  cavity  was  reticulated,  but  not  rough  in  its 
surface,  not  indicating  any  thing  like  caries.  ~No  sequestrum 
was  found  in  it,  though  it  doubtless  had  contained  one  which 
had  either  disintegrated  and  come  away  in  the  discharges,  or 
had  been  lost  in  the  maceration. 

With  regard  to  the  prognosis  of  such  fractures  of  the  in- 
volucrum,  my  experience  has  led  me  to  expect  their  prompt 
and  firm  union,  provided  the  original  disease  was  in  a  favor- 
able  condition,  and  the  sequestrum  could  be  entirely  removed. 

6.  Necrosis  after  Amputations. — It  happens  after  a  great 

many  amputations  that  the  healing  of  the  stump  is  delayed  by 

a  small  amount  of  necrosis  of  the  end  of  the  sawed  bone.     A 

ring  of  bone,  injured  by  the  violence  of  the  saw,  and  remain- 

13 


194  DISEASES  OF  BONE. 

ing  exposed  to  the  air  and  to  the  fluids  of  the  suppurating 
surface  of  the  stump,'  dies  and  separates,  usually  finding  its 
way  to  the  surface  some  weeks  after  the  amputation,  without 
interfering  with  the  healing  of  the  wound  in  any  other  way 
than  to  delay  it  (Fig.  34).  In  certain  other  cases,  fortunately 
much  more  rare,  the  necrosis  presents  more  extensive  and  more 
formidable  features,  sometimes  involving  almost  the  whole 
shaft  in  its  destructive  results.  This  form  of  necrosis  is  most 
commonly  seen  in  the  thigh-bone,  and  always  in  its  compact 
portion.  I  have  occasionally  observed  it  in  the  humerus,  and 
more  rarely  in  the  radius  and  ulna.  The  clinical  history  of 
such  a  case  is  about  as  follows :  After  an  amputation  of  the 
thigh,  every  thing  makes  a  satisfactory  progress  during  the  first 
few  weeks.  The  wound  heals  kindly,  the  ligatures  come  away, 
and  both  patient  and  surgeon  flatter  themselves  with  the  hopes 
of  an  early  cure.  It  is  observed,  however,  that  though  the 
ligatures  are  all  away,  and  no  apparent  cause  exists  to  prevent 
the  healing  of  the  small  portions  of  the  wound  which  still 
remain  open,  yet  the  wound  does  not  heal,  but  continues  at  one 
or  more  points  to  discharge  matter  in  quantity  altogether  out  of 
proportion  to  the  apparent  granulating  surface.  Soon  the  sores 
take  on  the  exuberant  pouting  appearance  of  the  granulations, 
round  the  orifices  from  which  matter  is  discharged,  which  at  once 
lead  to  the  suspicion  that  there  is  dead  bone  at  the  bottom  of 
the  sinuses  which  terminate  at  these  openings.  The  stump 
continues  tender,  and  now,  perhaps  several  weeks  after  the 
amputation,  shows  more  inflammatory  disposition  than  it  did 
soon  after  it  was  made.  The  stump  is  also  swollen  and  bulbous 
in  its  appearance ;  and  this  swelling  will  be  found  to  be  due  to 
an  enlargement  of  the  end  of  the  bone,  which  is  most  marked 
at  the  sawed  end,  and  diminishes  gradually  toward  the  tro- 
chanters.  A  probe,  introduced  at  one  of  the  fist ulous  openings, 
easily  recognizes  a  considerable  portion  of  dead  bone,  very  near 
the  surface  and  easily  accessible  for  removal.  The  patient  is 
feverish,  and  suffers  a  good  deal  of  uneasiness,  and  perhaps 
pain  in  the  stump,  which  ha  is  very  much  disappointed  in  not 
finding  healed  after  several  months  of  confinement.  If,  now, 
an  incision  be  made  on  the  face  of  the  stump,  and  the  end  of 
the  bone  exposed,  there  will  be  found  a  ring  of  dead  bone, 


NECROSIS.  195 

partly  concealed  by  bony  growth,  which  ring  represents  the 
sawed  end  of  the  bone.  It  will  be  observed,  however,  that  this 
ring  does  not  represent  the  whole  thickness  of  the  shaft,  but 
rather  its  inner  lamina,  which,  being  dead,  is  surrounded  by 
living  bone,  by  which  it  is  covered  in  as  by  a  thick  and  well- 
formed  involucrum.  On  seizing  this  ring  of  bone,  with  a 
strong  pair  of  forceps,  it.  will  be  found  to  be  movable,  but  it  is 
only  after  very  powerful  traction,  combined  with  twisting  and 
lateral  movements,  and  sometimes  after  their  long  and  ener- 
getic continuance,  that  the  sequestrum  starts  from  its  bed,  and 
we  draw  forth  one  of  those  long,  irregular  tubes  of  dead  bone, 
of  which  specimens  can  now  be  seen  in  every  museum.  These 
tubes  correspond  to  the  inner  lamellae  of  the  femur,  or  that 
which  looks  upon  the  medullary  cavity  of  the  bone,  as  is  shown 
by  the  size  of  the  inner  cavity  of  the  tube,  which  is  that  of  the 
medullary  canal ;  and  by  the  appearance  of  the  surfaces,  which 
on  the  inside  are  those  of  the  medullary  canal  unchanged, 
while  on  the  outside  we  have  the  irregular,  worm-eaten  surface, 
which  indicates  that  by  a  process  of  absorption  it  has  been 
separated  from  the  outer  lamellae,  which  have  maintained  their 
vitality.  Not  only  has  this  outer  portion  of  the  bone  main- 
tained its  life,  but  it  has  thickened  and  enlarged  itself  so  as  to 
cause  the  bulbous  expansion  of  the  end  of  the  bone  in  which 
involucral  expansion  the  sequestrum  has  been  enclosed.  These 
sequestra  vary  in  size  from  two  or  three  to  eight  or  nine  inches 
in  length.  They  are  generally  more  or  less  complete  cylinders, 
but  here  and  there  are  sometimes  found  openings,  through 
which  bony  granulations  from  the  involucrum  may  sometimes 
shoot,  thus  locking  the  sequestrum  fast  in  its  bed,  and  making 
it  difficult  or  impossible  to  remove  it  without  a  considerable 
operation.  The  following  case  illustrates  this  particular  diffi- 
culty, as  well  as  the  general  features  of  the  disease : 

James  Thompson,  aged  twenty-six,  had  his  left  thigh  ampu- 
tated, May  12,  1855,  in  the  New  York  Hospital,  for  an  injury 
to  his  knee-joint.  The  stump  healed  favorably,  till  only  a  small 
nicer  remained,  and  he  rapidly  recovered  strength  and  health. 
In  August  it  was  observed  that  the  wound  had  ceased  to  con- 
tract, that  the  end  of  the  femur  was  much  enlarged,  and  a 
probe,  passed  in  through  the  ulcer,  detected  dead  bone.  The 


196  DISEASES   OF  BONE. 

stump  now  began  to  be  occasionally  painful,  the  discharge  in- 
creased, and  he  was  evidently  losing  ground.  About  the  first  of 
September  'a  small  incision  was  made,  and  the  whole  circle  of 
the  cut  end  of  the  femur  was  found  necrosed.  An  attempt  was 
made  to  pull  out  the  dead  piece,  but  it  was  firmly  fixed  and 
was 'left.  The  mischief  in  the  stump  went  on  increasing. 
Abscesses  formed,  and  opened  in  various  directions.  The  dis- 
charge became  very  profuse,  and  the  patient  much  reduced  by 
fever  and  pain.  About  the  first  of  October  the  end  of  the 
stump  was  again  opened,  and  the  sequestrum  well  exposed  and 
seized  by  a  pair  of  powerful  forceps.  On  making  very  strong 
and  steady  traction  it  became  evident  that  the  piece  was  loose, 
and  soon  it  started  from  its  bed,  and  was  drawn  out  about 
three-quarters  of  an  inch,  but  beyond  that  point  no  force  could 
move  it.  It  could  be  pushed  back,  and  it  could  be  moved  a 
little  from  side  to  side,  but  it  could  not,  with  all  our  force,  be 
drawn  any  farther  out.  Supposing  that  it  was  locked  in  by 
bony  granulations  from  the  involucrum,  it  was  left  drawn  out 
as  far  as  it  would  come,  and  each  day  traction  was  made  upon 
it,  hoping  thus  to  cause  the  absorption  of  the  new  bony  deposit 
which  impeded  its  extrication.  This  result,  however,  was  not 
realized,  and  at  the  end  of  a  month  the  sequestrum  was  as  in- 
extricable as  ever,  and  the  condition  of  the  stump,  as  well  as 
of  the  patient's  general  health,  was  rapidly  deteriorating.  On 
the  2d  of  November  I  made  a  free  incision  over  the  anterior 
and  outer  face  of  the  stump,  and,  exposing  the  involucrum,  I 
•  commenced  removing  it  round  the  end  of  the  projecting  seques- 
trum. The  removal  of  three-quarters  of  an  inch  all  around  did 
not  liberate  the  sequestrum.  I  then  broke  up  some  osseous 
matter  which  had  formed  a  sort  of  cylinder  within  the  seques- 
trum, and  thus  I  discovered  that  from  this  internal  ossification 
a  spur  or  process  of  bone  passed  through  an  opening  in  the 
sequestrum,  and  joined  itself  to  the  involucrnm  without,  thus 
nailing  the  loosened  bone  in  its  cavity,  but  permitting  it  to 
move  backward  and  forward  about  three-fourths  of  an  inch. 
This  spur  being  cut  by  the  chisel,  it  was  found  that  the  seques- 
trum was  released,  and  it  was  easily  drawn  out.  The  stump 
improved  immediately  after  the  removal  of  the  dead  bone,  and 
healed  slowly.  He  was  discharged  cured,  May  6,  1868.  This 


NECROSIS.  197 

operation  drew  my  attention  to  this  inner  cylinder  of  bone, 
which,  as  far  as  I  know,  has  not  been  noticed  by  any  who  have 
written  on  this  subject.  It  plays  so  important  a  part  in  this 
disease,  that  I  present  the  continuation  of  the  history  of  the 
above  case,  in  which  the  relations  of  this  inner  cylinder  became 
more  distinct.  The  man  continued  well  during  the  summer 
following  his  leaving  the  hospital,  but  unfortunately  had  a  fall 
which  caused  reulceration  of  the  stump.  He  came  back  to  the 
hospital,  and,  as  the  soft  parts  had  from  long-continued  disease 
shrunk  away,  leaving  the  thickened  end  of  the  bone  unduly 
prominent,  this  thick  bulbous  end  was  exposed  by  an  in- 
cision, and  one  inch  and  a  half  of  its  extremity  sawed  off. 
This  left  the  stump  in  a  good  condition  to  heal  soundly,  which 
it  did  without  further  trouble.  On  maceration,  the  removed 
segment  proved  to  be  perfectly  sound  and  healthy  bone,  but 
very  much  changed  in  size  and  form.  It  was  twice  the  diam- 
eter of  the  sound  femur,  and.  the  expanded  extremity  had  a 
rougher  and  more  irregular  surface.  The  section  showed  its 
structure  to  be  that  of  a  double  cylinder,  the  outer  one  being 
very  thick,  the  inner  one  being  quite  thin.  "Within  the  inner 
cylinder  the  medullary  canal  existed  of  a  size  and  appearance 
quite  natural.  Between  the  outer  and  the  inner  cylinder,  a 
narrow,  cylindrical,  vacant  space  existed,  from  which  it  was 
evident  that  the  sequestrum  had  been  removed.  The  substance 
of  both  cylinders  was  spongy  and  porous,  indicating  clearly 
that  the  changes  were  of  recent  occurrence.  Figs.  35  and  36 
show  these  appearances  very  distinctly. 

The  explanation  of  the  occurrence  of  these  sequestra,  and 
the  reason  of  their  peculiar  configuration,  have  not  attracted 
much  attention  from  surgical  writers.  Mr.  Syme  alludes  to 
them  as  produced  by  injury  done  to  the  medullary  membrane, 
whereby  the  inner  lamina  of  bone  nourished  by  that  mem- 
brane dies  and  exfoliates  in  a  tubular  form,  an  explanation 
which,  as  far  as  it  goes,  seems  to  me  correct ;  but  what  the 
nature  of  that  injury  is,  and  how  it  is  brought  about,  are 
questions  which  yet  remain  to  be  answered.  If  we  admit 
that  the  necrosis  is  of  the  inner  lamellae  next  to  the  medulla, 
and  this  seems  to  be  undeniable,  then,  inasmuch  as  these 
inner  lamellae  receive  their  nourishment  from  the  medullary 


198 


DISEASES   OF  BOXE. 


arteries,  it  would  seem  certain  that  the  mischief  must  be  due  to 
some  action  in  the  medullary  circulation,  whereby  this  particu- 
lar portion  of  the  bone  loses  its  vascular  supply.  J^ow,  this 
may  be  produced  in  various  ways.  It  may  be,  for  example, 
that  the  medulla  is  killed  by  the  direct  vio- 
lence of  the  saw,  as  we  often  see  lacerated  and 
contused  wounds  elsewhere  mortify  on  their 
surface.  That  this  is  often  the  case,  and  that 
such  a  death  may  explain  the  narrow  ring  of 
bone  which  often  exfoliates  from  the  sawed  end, 
I  am  not  disposed  to  deny ;  but  that  such  vio- 
lence could  extend  so  far  as  eight  or  nine  inches 
up  into  the  stump,  and  produce  its  effects  with- 
out entirely  destroying  the  medulla  itself,  it 
does  not  seem  to  me  reasonable  to  believe. 
Again,  it  might  be  supposed  that  inflammation 
attacking  the  medulla,  and  suppuration  occur- 
ring, might  separate  the  bone  from  the  vascular 
substance  of  the  medulla,  and  thus  produce  its 
necrosis.  But  such  an  inflammation  would  be 
accompanied,  we  may  well  suppose,  with  very 
marked  and  probably  very  serious  symptoms, 
both  local  and  general,  such  as  accompany  OS- 
FIG.  35.— (sr.Y.Hos-  teo-myelitis,  wherever  it  occurs,  under  other  cir- 
cumstances. No  such  symptoms  are  present, 
however,  in  cases  where  the  most  extensive  sequestrum  is 
found;  in  fact,  the  cases  presenting  this  trouble  are  usually 
most  favorable  in  their  demeanor  during  all  the  early  period 
of  their  healing,  many  of  them  not  presenting  a  bad  symptom 
until  the  evidences  of  necrosis  begin  to  show 
themselves,  and  even  then  these  evidences  accu- 
mulate slowly  from  day  to  day,  not  being  pre- 
ceded by  any  thing  which  can  stand  for  an  ap- 
parent cause.  We  are,  therefore,  it  seems  to 
me,  debarred  from  assuming  either  direct  injury 
of  the  medulla,  or  suppurative  inflammation  of 
it,  as  the  cause  of  these  peculiar  sequestra. 
Some  cause  must  be  found  which  will  explain  all  the  phe- 
nomena, and  this  cause,  I  think,  it  is  not  difficult  to  arrive  at. 


FIG.  36.— (N.  T.  Hos- 
pital Museum.) 


NECROSIS.  199 

If  \ve  suppose  that  the  nutritious  artery  of  the  bone  is  divided 
either  by  the  saw  while  in  its  bony  canal,  or  by  the  knife  before 
it  has  entered  it,  then  we  have  the  vascular  supply  of  the 
medulla  temporarily  suspended.  The  inner  lamellae  of  the 
bone,  depending  for  their  supply  on  the  medulla,  are  also 
deprived  of  their  circulation.  The  medulla  itself,  having  vas- 
cular connections  with  the  upper,  spongy,  and  more  vascular 
portion  of  the  bone,  gradually  recovers  its  supply  of  blood  by 
anastomosis,  and  probably  never  dies  from  this  temporary  cut- 
ting off  of  its  circulation,  but  in  the  mean  time  its  circulation 
is  so  enfeebled  that  it  can  supply  nothing  to  the  bone,  and  this 
has  no  resource  but  in  its  anastomosis  with  the  outer  lamellae, 
nourished  by  the  periosteum.  The  vessels  of  the  outer  lamellae, 
anastomosing  with  those  of  the  inner  lamellae  by  capillaries 
enclosed  in  unyielding  walls,  cannot  dilate  with  sufficient 
rapidity  to  meet  effectively  the  sudden  demand  upon  them,  and 
thus  it  happens  that  for  a  time  the  circulation  of  the  inner 
lamellae  is  entirely  suspended,  sometimes  sufficiently  long,  I 
believe,  to  bring  about  its  death.  This  will  account  for  the 
necrosis  presenting  no  symptoms  until  the  presence  of  the  dead 
bone  begins  to  announce  itself.  It  also  explains  why  the  ne- 
crosis limits  itself  to  the  inner  lamellae,  and  why  the  sequestrum 
is  embraced  between  two  tubes,  one  the  outer  periosteal  por- 
tion, which  has  thickened  itself  gradually  into  an  involucrum, 
and  the  other  a  thin  cylinder  of  ossification  of  the  surface  of  the 
medulla,  which  has  recovered  all  its  vitality  after  a  temporary 
suspension  of  its  circulation.  It  will  also  explain  why  it  is  that 
the  upper  end  of  the  sequestrum  grows  thinner,  and  branches 
into  slender  terminal  spiculae  of  a  very  irregular  and  sometimes 
fantastic  form.  This  is  the  outline  of  parts  dead  from  loss  of 
capillary  circulation,  a  loss  which  is  better  and  more  quickly 
compensated  above,  by  the  greater  facility  of  anastomotic  sup- 
ply in  the  upper,  spongy,  than  in  the  lower,  compact  portion  of 
the  bone.  If  this  be  accepted  as  a  possible  explanation  of  the 
phenomena  before  us,  it  remains  to  show  that  it  is  a  probable 
one.  This  we  arrive  at  by  observing  the  course  of  the  nutri- 
tious artery  as  it  enters  the  bone.  In  examining  forty-five 
femora  contained  in  several  museums  in  this  city,  I  found  that 
in  twenty-three  the  nutritious  foramen  was  situated  about  the 


200  DISEASES  OF  BOXE. 

junction  of  the  upper  and  middle  third,  and  in  twenty-two  it 
was  at  or  near  the  middle  of  the  bone.  In  several  instances  it 
was  double.  The  direction  of  the  canal,  in  every  instance,  was 
from  below  upward.  The  artery  itself  is  given  off  from  the 
middle  perforating  branch  of  the  femoral,  and  runs  upward  a 
certain  distance  before  it  enters  the  canal,  and  thus  we  have  a. 
space  of  an  inch,  more  or  less  in  different  individuals,  in  which 
if  the  knife  or  saw  happen  to  fall  it  will  divide  the  artery,  and, 
when  we  consider  that  this  dangerous  inch  is,  in  twenty-two 
cases  out  of  forty-five,  at  the  very  middle  of  the  bone,  we  can 
well  believe  that  it  will  be  traversed  either  by  the  knife  or  by 
the  saw,  in  a  considerable  proportion  of  the  amputations  of  the 
thigh,  which  are  done  through  its  middle  third. 

7.  Necrosis  without  Suppuration. — The  occurrence  of  sup- 
puration in  consequence  of  necrosis  is  so  universal  that  its  occa- 
sional failure  to  demonstrate  its  presence,  by  abscess  and  fistulas 
leading  to  the  surface,  becomes  worthy  of  special  consideration. 
Mr.  Stanley  remarks:  "Only  a  single  exception  to  this  lias 
occurred  within  my  own  observation,  which  was  in  an  instance 
of  necrosis  affecting  portions  of  the  inner  lamellae  of  the  femur 
and  of  the  tibia  in  the  same  individual.  Here  the  perished 
inner  lamellae  have  completely  separated  from  the  living  bone ; 
yet  there  is  no  fistulous  passage  in  the  walls  either  of  the  femur 
or  of  the  tibia."  I  have  now  under  my  care  a  case  of  a  young 
gentleman,  son  of  a  medical  friend,  in  whom  all  the  symptoms 
of  necrosis  developed  themselves  more  than  a  year  ago,  and  yet, 
no  abscess  having  formed,  we  have  been  in  doubt  as  to  the 
nature  of  the  case,  till  within  a  few  weeks,  when  a  swelling 
occurred  on  the  inside  of  the  thigh,  the  femur  being  the  bone 
supposed  to  be  involved,  which  swelling  gradually  assumed  the 
external  form  of  abscess ;  that  is  to  say,  it  was  prominent  from 
the  surrounding  surface,  somewhat  red  on  its  apex,  and  gave 
an  obscure  feeling  of  fluctuation.  After  watching  it  for  a 
number  of  weeks,  hoping  for  more  distinct  evidences  of  matter, 
and  finding  no  progress,  we  determined  to  make  an  explorative 
incision.  This  was  done,  and,  after  passing  deeply  down 
toward  the  bone,  through  brawny,  thickened  tissue,  we  came 
upon  a  cavity  from  which  flowed  a  small  quantity  of  pus,  but 
which  was  mainly  occupied  by  a  soft,  reddish-yellow  substance, 


NECROSIS.  201 

of  a  jelly-like  consistency,  which  could  be  scooped  out  of  the 
cavity  in  quantities,  but  seemed  rather  like  imperfect  granula- 
tion-substance than  like  any  modification  of  pus.  The  cavity 
being  cleared,  extensive  necrosis  of  the  posterior  surface  of  the 
femur  was  discovered.  This  delay  or  absence  of  the  signs  of 
suppuration  has  occurred  to  me  in  one  or  two  other  instances, 
and  has  led  me  to  be  cautious  in  positively  deciding  against 
the  existence  of  necrosis  from  the  mere  absence  of  the  ordinary 
manifestations  of  the  formation  of  pus. 

8.  Necrosis  without  Exfoliation. — I  have  already  spoken  of 
the  indisposition  to  separation  which  is  manifested  by  certain 
cases  of  necrosis  of  the  cranium,  and  also  of  the  lower  jaw. 
The  same  hesitancy  to  cast  off  the  dead  bone  is  seen  in  other 
cases,  principally,  I  suspect,  in  those  of  a  syphilitic  character. 
The  following  case  is  an  example : 

James  Becket,  aged  thirty-eight,  a  seaman,  was  admitted 
into  the  New  York  Hospital,  March  25,  1857,  with  epilepsy 
and  amaurosis,  supposed  to  be  connected  with  an  old  injury  of 
the  head,  and  for  which  he  was  trephined  by  Dr.  Van  Buren 
on  the  30th.  He  had,  at  the  same  time,  an  oval  ulcer  on  his 
left  leg,  which  was  about  three  inches  long,  and  nearly  two 
inches  wide,  the  bottom  of  which  was  entirely  formed  of  dead, 
black,  and  fetid  bone.  He  said  that  he  had  had  syphilis  a  great 
many  times,  and  that  this  sore  formed  on  his  leg  about  seven 
months  ago.  For  at  least  four  months  the  bone  had  been  lying 
exposed  and  black  on  the  bottom  of  the  ulcer.  It  was  an  in- 
dolent sore,  and  but  little  thickening  of  the  surrounding  tissues 
and  no  enlargement  of  the  bone  existed.  On  pressing  rudely 
on  the  bone  it  gave  no  pain,  and  it  was  observed  to  be  entirely 
immovable.  It  was  thought  best  to  remove  the  dead  portion 
of  bone,  and  for  this  purpose  the  integuments  were  raised  from 
the  anterior  surface  of  the  tibia,  all  around  the  blackened  and 
dead  spot,  which  was  found  not  to  extend  any  farther  than  the 
part  which  lay  exposed  in  the  ulcer.  On  clearing  the  surface, 
no  sign  of  a  line  of  demarcation  could  be  seen  between  the 
dead  and  the  living  parts,  and  much  less  any  furrow  or  other 
indication  of  commencing  separation.  A  slight  irregular  mar- 
gin of  new  bony  deposit  existed  at  points  near  where  the  living 
and  dead  bone  joined,  but  the  only  way  of  distinguishing  be- 


202  DISEASES   OF  BONE. 

tween  the  two  was  in  the  fact  that  one  part  bled  when  chiselled 
and  the  other  did  not.  Taking  this  as  our  guide,  the  chisel 
was  freely  but  carefully  used,  until  the  whole  surface  bled 
freely.  In  order  to  accomplish  this,  nearly  the  whole  thickness 
of  the  anterior  wall  of  the  tibia  was  removed,  and  a  consider- 
able portion  on  each  side,  the  necrosis  having  occupied,  like  a 
saddle,  nearly  the  anterior  half  of  the  compact  substance  of  the 
bone.  There  was  no  more  indication  of  any  commencing 
process  of  separation  in  the  internal  and  deeper  point  of 
union  between  the  living  and  dead  bone,  than  had  been  ob- 
served at  the  surface.  No  serious  accident  occurred  during 
the  healing  of  the  wound,  the  bone  granulated  sluggishly, 
but  without  any  further  necrosis,  and  the  wound  was  nearly 
healed  when  he  was  discharged  from  the  hospital,  August  10, 
1857. 

Another  instance  of  marked  indisposition  to  separation  oc- 
curred in  a  case  of  necrosis  which  presented  features  which,  in 
many  Respects,  were  so  peculiar  that  I  venture  to  give  the  his- 
tory in  detail : 

Charles  Jones,  aged  twenty-three,  by  occupation  a  clerk,  had 
suifered  for  many  years  with  a  diseased  condition  of  the  tibia, 
of  which  he  gives  the  following  account :  At  about  the  age  of 
eight  years  he  had  an  attack  of  inflammation  of  the  left  leg, 
which  left  the  bone  enlarged,  and  the  seat  of  more  or  less  con- 
stant tenderness,  heat,  and  pain.  About  the  age  of  thirteen 
an  incision  was  made  down  through  the  thickened  bone  with  a 
trephine  and  chisel,  but  no  sequestrum  was  found  nor  any  pus. 
This  operation,  however,  was  followed  by  some  improvement 
in  the  condition  of  the  limb,  and,  after  the  wound  healed,  it 
remained  diminished  in  size,  and  less  troublesome  to  him.  For 
eight  years  the  disease  remained  in  a  quiet  condition,  until 
about  two  years  previous  to  my  seeing  him,  when  an  abscess 
formed  on  the  anterior  face  of  the  limb,  which  did  not  heal, 
but  degenerated  into  an  open  ulcer,  at  the  bottom  of  which 
could  be  felt  exposed  bone.  This  ulcer  increased  gradually 
until  I  saw  him,  in  March,  1859.  At  this  time  it  was  five 
inches  long,  by  one  and  a  half  broad,  and  the  entire  base  of  it 
was  formed  by  the  blackened,  necrosed  surface  of  the  tibia.  It 
gave  him  but  little  pain,  but  the  discharge  from  it  was  con- 


NECROSIS.  203 

siderable,  and  of  so  abominable  and  penetrating  an  odor  that, 
with  every  attention  to  cleanliness,  he  could  not  keep  himself 
free  from  it ;  and  it  was  mainly  this  which  made  him  anxious 
to  have  something  done  for  the  relief  of  his  disease.  Although 
there  was  no  sign  of  loosening  of  the  dead  parts,  yet  the  se- 
questrum was  so  superficial  and  so  accessible  that  we  had  no 
hesitation  in  recommending  an  operation,  which  was  performed 
by  Dr.  Buck.  It  consisted  in  still  further  exposing  the  front 
of  the  tibia,  by  dissecting  back  the  integuments,  and  then,  with 
chisels  and  gouges,  removing  the  dead  mass.  We  did  not  find 
merely  death  of  bone,  as  we  expected,  but,  as  the  chisel  re- 
moved the  most  superficial  blackened  layer,  it  was  found  to  be 
merely  the  exposed  and  dried  surface  of  bone,  which,  at  a  line 
or  two  of  depth,  presented  a  condition  of  infiltrated  suppura- 
tion. As  cut  by  the  chisel,  the  bone  presented  very  much  the 
appearance  of  a  lung  in  the  third  stage  of  hepatization,  though 
the  pus  was  so  concrete  that  none  flowed  out.  As  the  gouge 
penetrated  more  deeply,  the  substance  of  the  bone  became  more 
vascular  and  less  infiltrated  with  pus.  The  diseased  part  was 
thoroughly  and  carefully  removed,  and  was  found  to  have  pene- 
trated at  its  central  portions  about  an  inch  toward  the  centre 
of  the  bone,  which,  of  course,  was  much  thickened  and  consoli- 
dated by  long-continued  disease.  The  surface  left  on  the  com- 
pletion of  the  operation  seemed  healthy,  was  fully  vascular,  and 
presented  the  appearance  of  bone  the  vessels  of  which  have 
been  enlarged  by  the  proximity  of  long-continued  inflamma- 
tion. Great  constitutional  irritation  followed  the  operation, 
and  for  a  long  time  he  remained  in  an  exceedingly  depressed, 
nervous,  and  feeble  state.  Gradually  he  rallied,  and  slowly 
convalesced.  The  wound  granulated  over  a  great  part  of  its 
surface,  but  the  margins  of  the  excavated  bone  seemed  to  take 
on  a  condition  very  similar  to  that  which  existed  previous  to 
the  operation.  This  striking  difference,  however,  existed  in  the 
behavior  before  and  after  the  operation,  viz. :  that  after  the 
operation  the  dead  parts  separated,  and  some  exfoliated  in  a 
perfectly  natural  manner,  in  the  course  of  a  few  weeks,  while 
before  the  operation  separation  refused  to  commence,  even 
after  the  lapse  of  years.  His  condition  remained  unsatisfac- 
tory, with  every  evidence  of  Bright's  disease  of  the  kidneys. 


204  DISEASES  OF  BONE. 

The  wound  was  granulating  languidly,  and  slowly  improving, 
when  he  died  August  17,  1868. 

It  is  not  easy  to  explain  why  it  is  that  in  these  cases  the 
failure  to  accomplish  separation  should  be  so  marked  a  feature, 
even  after  the  lapse  of  so  long  a  period,  but  I  think  that  in  all 
the  cases  I  have  observed  there  has  been  some  general  cachexia 
which  may  stand  for  one  step  toward  the  solution  of  the  prob- 
lem. In  the  jaws  it  seems  to  be  the  poison  of  phosphorus  or 
mercury;  in  many  other  cases  it  may  be  scrofula;  but  I  am 
quite  certain  that  much  the  larger  number  of  cases  are  con- 
nected with  syphilis ;  and  it  is  reasonable  to  suppose  that  the 
peculiarities  of  the  behavior  of  the  disease  are  due  to  the 
peculiar  constitutional  conditions  under  which  it  is  developed. 

The  general  principles  of  treatment  of  necrosis  may,  it  seems 
to  me,  be  very  easily  and  naturally  deduced  from  the  history  of 
the  disease  as  it  has  now  been  given.  Three  indications  present 
themselves:  1.  To  prevent  or  relieve  the  inflammation  upon 
which  the  necrosis  depends,  or  which  arises  in  consequence  of  it ; 

2.  To  promote  the  separation  of  the  dead  from  the  living  bone ; 

3.  To  remove  or  to  facilitate  the  removal  of  the  sequestrum  : 

1.  To  prevent  or  relieve  Tn/lammation. — So  evident  is  the 
dependence  of  necrosis  upon  inflammation,  that  we  might 
safely  say  that  by  preventing  inflammation  we  can  prevent  the 
necrosis.  It  very  rarely  happens,  however,  that  we  can  in 
reality  prevent  an  inflammation,  in  the  strict  sense  of  the 
word;  but  the  same  principle  is  illustrated  in  those  cases 
where,  by  the  prompt  abatement  of  the  inflammation,  we  pre- 
vent its  evil  consequences.  There  are  two  ways  in  which  this 
prompt  abatement  can  be  attained :  the  first  by  the  very  active 
use  of  antiphlogistic  remedies  locally  applied ;  and,  secondly, 
by  removing  the  tension  and  pressure  produced  by  accumu- 
lating effusions,  by  making  free  incisions  down  through  the, 
periosteum  to  the  bone  itself.  The  first  plan  is  illustrated  by 
the  case  of  whitlow,  where,  by  making  free  use  of  leeches 
and  other  antiphlogi sties,  in  the  earliest  stages,  we  can  often 
succeed  in  putting  a  prompt  period  to  processes  which  we 
know,  if  not  thus  treated,  are  very  sure  to  be  followed  by 
necrosis  of  the  affected  phalanx.  The  principle  is  applicable 
to  all  inflammations  affecting  the  bones,  of  such  acuteness  and 


NECROSIS.  205 

severity  as  to  lead  us  to  apprehend  necrosis.  Of  course,  in  a 
large  bone,  like  the  tibia,  we  should  not  expect  to  attain  the 
same  complete  results  that  we  often  do  in  the  finger,  but  by 
the  active  and  energetic  use  of  antiphlogistic  treatment,  in  the 
earlier  stages  of  inflammation,  we  may  mitigate  the  severity, 
and,  I  believe,  may  materially  abridge  the  destructive  tenden- 
cies of  the  case. 

The  second  mode  of  abating  inflammation,  that  by  mak- 
ing free  incisions  through  the  membranous  covering  of  the 
bones,  is  useful  at  all  periods  of  the  disease,  but,  of  course, 
as  a  preventive  measure,  most  effective  during  the  earlier 
stages.  In  the  large  bones,  and  particularly  in  the  deeply- 
seated  ones,  it  becomes  so  serious  an  operation,  however,  that, 
in  the  uncertainty  of  diagnosis  which  generally  characterizes 
the  earlier  periods  of  necrosis,  it  may  be  doubtful  whether 
it  can  often  be  available.  I  have  known  it  to  be  employed  in 
one  case  in  this  city,  in  a  little  boy,  in  whom  a  sudden  inflam- 
mation attacking  the  shaft  of  the  tibia,  an  incision  was  made 
by  the  late  Dr.  John  Watson,  along  the  whole  anterior  surface 
of  the  bone,  dividing  the  periosteum  down  to  the  bone.  In 
this  case  the  inflammation  had  existed  long  enough  to  produce 
effusion  between  the  bone  and  periosteum,  for  the  latter  mem- 
brane gaped  open  on  being  incised,  exposing  bone  already  bare, 
which  soon  became  evidently  dead.  No  good  effect  could  be 
traced,  in  this  instance,  on  the  progress  of  the  disease,  for  the 
whole  shaft  of  the  tibia  necrosed,  but  our  conviction  at  the 
time  was  that,  if  the  incision  could  have  been  made  early,  it 
might  have  been  more  effectual,  at  least  in  limiting  the  extent, 
if  not  in  preventing  the  occurrence  of  necrosis.  The  enormous 
wound  made  in  this  mode  of  operating,  and  the  exposure  of 
the  bone  to  the  air,  are  serious  objections  to  it,  and  must  very 
much  curtail  its  application.  In  these  respects  the  subcuta- 
neous section  offers  advantages  which  I  think  entitle  it  to  a 
more  extended  trial  than  it  has  yet  had. 

2.  To  promote  the  Separation  of  the  Dead  from  the  Living 
Bone. — And  here,  the  first  question  which  presents  itself  is, 
Can  any  thing  be  done  to  promote  this  separation  ?  I  am 
disposed  to  answer  this  question  in  the  negative,  as  far  as  re- 
lates to  the  disease  in  its  ordinary  forms,  and  in  tolerably 


206  DISEASES  OF  BONE. 

healthy  constitutions.  It  may  well  be  conceived,  however, 
that  there  may  be  certain  conditions,  both  of  the  part  and 
of  the  general  system,  where  sluggishness  and  inactivity  char- 
acterize the  morbid  actions,  and  where  stimulation,  both  local 
and  general,  would  seem  to  be  clearly  indicated.  .  The  local 
stimulants  would  be  those  which  we  would  use  in  a  corre- 
sponding case  in  the  soft  parts,  such  as  a  solution  of  some 
stimulating  tinctures,  or  of  the  sulphates  of  zinc  and  copper, 
the  balsams  of  Peru  and  of  fir,  either  made  into  an  ointment  or 
applied  pure,  or  a  weak  solution  of  the  bichloride  of  mercury. 
Each  of  these  classes  of  stimulants,  in  its  appropriate  case, 
either  applied  to  the  granulating  surfaces,  or  injected  into  the 
suppurating  cavities,  may  have,  I  do  not  doubt,  a  good  effect 
in  promoting  the  separation  of  the  sequestrum,  if  Nature  be 
dilatory  in  bringing  the  separation  about.  At  the  same  time 
such  general  remedies  as  will  improve  the  general  vigor,  and 
increase  the  tone  of  all  the  active  functions  of  the  body,  will 
also  assist  in  bringing  about  the  desired  result.  But  it  seems 
to  me  that  it  is  wise  not  to  do  too  much  in  this  direction,  lest 
our  stimulation  excite  new  inflammation,  believing  that  Nature 
will,  in  the  large  proportion  of  cases,  do  more  and 'better  for 
us  than  we  can  do  for  her.  And,  as  deduced  from  this  same 
view  of  the  case,  I  would  object  to  any  mechanical  means 
being  adopted,  by  instruments  introduced  either  between  the 
separating  bones,  or  between  the  periosteum  and  the  bone,  in 
the  view  of  expediting  the  separation,  or  of  preserving  the 
periosteum,  believing  that  this  instrumental  interference  will 
not  do  good,  and  will  be  liable  to  do  much  harm. 

The  Removal  of  the  Sequestrum. — There  are  a  few  cases  of 
this  disease  where  the  necrosis  is  slight,  and  where  it  is  near  the 
surface  of  the  body,  in  which  Nature  is  competent  to  cast  off  the 
sequestrum  and  remove  it  from  the  body  without  the  assistance 
of  art.  In  all  cases,  however,  where  the  dead  part  has  any 
considerable  size,  and  particularly  where  it  lies  deeply  from  the 
surface  of  the  body,  some  process  of  extrication  is  necessary, 
either  from  its  encasement  in  the  new  bony  formation,  or  from 
the  soft  parts  which  surround  it,  and  these  processes  sometimes 
assume  the  proportions  of  a  most  formidable  operation.  Taking 
it  for  granted,  then,  that  some  operation  will  be  required,  two 


NECROSIS.  207 

questions  present  themselves :  first,  as  to  the  time  when,  and, 
second,  as  to  the  mode  in  which,  the  operation  shall  be  per- 
formed. The  time  when  an  operation  for  the  removal  of  a 
sequestrum  shall  be  undertaken,  other  things  being  equal,  will 
depend  upon  one  thing  only,  namely,  the  fact  of  the  separation 
of  the  dead  from  the  living  bone  being  so  perfectly  accom- 
plished that,  when  the  sequestrum  is  released  from  its  sur- 
rounding entanglements,  it  can  be  easily  and  entirely  removed. 
Any  condition  short  of  this  is  a  centra-indication  of  the  opera- 
tion. And  this  for  obvious  reasons.  If  separation  have  not 
completely  taken  place,  though  we  may  be  able  to  seize  and 
bring  away  the  bulk  of  the  sequestrum,  yet  we  run  the  risk  of 
leaving  behind  some  of  the  undetached  portion,  and  this  will 
usually  happen  at  the  deepest  and  most  inaccessible  portion  of 
the  wound,  and  thus  the  operation  fails  of  its  purpose,  which 
is,  the  complete  removal  of  all  the  dead  mass.  Again,  if  sepa- 
ration have  not  taken  place,  we  may  find  ourselves  unable  to 
detach  the  sequestrum  at  all  without  risk  of  fracturing  the 
bone  whose  integrity  we  are  trying  to  save.  This  is  an  acci- 
dent which  has  sometimes  happened  where  surgeons  have  felt 
it  necessary,  for  reasons  peculiar  to  the  case,  to  disregard  the 
rule,  and  operate  without  waiting  for  complete  loosening  of  the 
sequestrum ;  and  it  has  this  peculiar  feature  of  disadvantage, 
that,  if  under  such  circumstances  a  fracture  do  occur,  there 
is  left  between  the  fragments  a  portion  of  unremoved  seques- 
trum, which  makes  a  very  serious  complication  of  the  case. 

This  rule  of  surgery,  then,  being  accepted,  the  next  point  is 
to  ascertain  the  fact  of  complete  separation,  as  an  indication  that 
the  time  for  operation  has  arrived.  In  many  cases  this  can  be 
done,  with  great  ease,  by  the  touch  of  the  probe,  which  imme- 
diately reveals  the  fact  that  the  dead  piece  is  movable;  but 
there  are  a  number  of  cases  which  present  themselves,  where 
the  ascertainment  of  actual  separation  is  not  so  easy.  The 
granulations  which  spring  from  the  walls  of  the  cavity  in  which 
the  sequestrum  lies,  by  pressing  upon  it  from  all  sides,  may 
hold  it  so  firmly  that  no  movement  can  be  elicited  by  the  mere 
pressure  of  the  probe.  Under  these  circumstances,  if  one  probe 
be  introduced  at  one  opening,  and  another  through  another, 
some  distance  off,  then,  by  making  pressure  alternately,  with 


208  DISEASES  OF  BOXE. 

one  and  the  other,  a  seesaw  motion  of  the  sequestrum  may  be 
perceived,  which  is  sufficient  to  prove  that  it  is  entirely  de- 
tached. Again,  by  introducing  a  straight  steel  sound  down  to 
the  dead  bone,  and  making  forcible  pressure  for  a  moment,  and 
then  relaxing  it,  repeating  the  manoeuvre  frequently,  and  with 
considerable  force,  the  loose  piece  will  gradually  be  pressed 
down  into  the  soft  granulations,  and  make  thus  a  space  in 
which  its  movements  can  be  readily  appreciated.  There  re- 
main, however,  a  certain  number  of  cases  in  which  no  physical 
examination  will  entirely  satisfy  us  that  the  bone  is  loose,  and 
in  these  cases  we  have  to  trust  to  probabilities.  If  the  death 
of  bone  have  been  ascertained  to  have  existed  for  a  certain  time, 
if  the  discharge  have  been  about  uniform  during  this  time,  if 
the  other  symptoms  have  undergone  no  change,  and  if  the 
orifice  of  the  sinuses  show  the  pouting,  exuberant  granulations, 
then  we  may  believe  that  separation  has  occurred.  The  length 
of  time  required  for  the  completion  of  the  process  has  not 
been  ascertained,  nor  is  it  supposed  to  be  uniform,  but  I  have 
been  accustomed  to  think  that  in  a  healthy  adult  about  three 
months  would  be  a  safe  period  to  adopt,  varying  of  course 
somewhat  in  individual  cases.  In  children  separation  takes 
place  much  sooner. 

Having  ascertained  that  the  sequestrum  is  loose,  it  is  then 
the  duty  of  the  surgeon  to  remove  it.  As  a  general  rule,  nothing 
is  to  be  gained  by  delay,  and  the  presence  of  the  dead  mass  is 
always  a  source  of  suffering  and  danger.  Two  conditions  of  the 
sequestrum  present  themselves  in  reference  to  an  operation : 
one  where  it  is  covered  in  and  imprisoned  only,  or  mainly  by 
the  soft  parts ;  and  one  where  it  is  so  encased  in  involucral  for- 
mation that  it  cannot  be  extricated  except  by  cutting  away  some 
of  the  newly-formed  bone  which  encloses  it.  In  the  first  con- 
dition but  little  is  required  except,  by  incision  of  the  soft  parts, 
to  liberate  the  bone ;  but  sometimes,  when  the  sequestrum  is 
small,  and  when  it  lies  very  deep  from  the  surface,  its  libera- 
tion is  not  thus  immediately  effected.  This  is  often  an  embar- 
rassment which  we  encounter  in  trying  to  get  rid  of  those 
small  sequestra  which  form  on  the  ends  of  the  fragments  in 
compound  fractures.  These,  sometimes,  without  being  en- 
closed in  any  bony  casing,  are  so  inaccessible,  from  their 


NECROSIS.  209 

depth,  and  perhaps  their  concealed  position  between  the  frag- 
ments, that  an  incision  of  the  soft  parts  does  not  help  us  much 
in  their  removal.  In  these  cases  the  use  of  the  sponge-tent, 
by  dilating  the  wound,  gives  us  a  better  access  to  the  foreign 
body,  and  enables  the  forceps  to  open  more  readily,  and  thus 
to  seize  more  firmly  the  presenting  part.  It  is  important,  in 
such  cases,  to  use  repeated  tents  until  the  wound  is  largely 
dilated,  and  to  thrust  them  well  down  to  dead  bone,  so  that 
the  thorough  dilatation  shall  reach  the  imprisoned  sequestrum. 

Where  the  dead  bone  is  closely  encased  in  the  involucruin, 
then  a  more  serious  and  well-considered  procedure  becomes 
necessary.  The  first  step  of  these  operations  should  consist  in 
exposing  the  most  accessible  surface  of  the  involucrum,  so  as  to 
bring  it  under  the  reach  of  the  trephine  and  the  chisel.  In  the 
tibia  this  is  of  course  the  anterior  surface,  but  in  some  of  the 
deeper-seated  bones,  as  the  femur,  it  is  a  matter  of  nice  con- 
sideration as  to  the  side  on  which  to  approach  the  sequestrum. 
As  a  general  rule,  that  side  on  which  the  fistulous  openings  exist 
will  present  the  sequestrum  most  superficial ;  but  this  may  not 
be  the  most  favorable  direction  for  the  incisions  by  reason  of  im- 
portant vessels  and  nerves,  as  is  often  felt  by  the  surgeon  to  be 
the  case  in  those  common  cases  of  necrosis  of  the  posterior  sur- 
face of  the  femur  near  the  knee-joint.  Here,  the  presence  of  the 
artery  and  nerves  is  an  embarrassment  wThich  is  to  be  avoided 
by  a  circuitous  rather  than  a  direct  approach  to  the  diseased 
bone ;  and  as  a  general  rule  this  approach  is  usually  made  from 
the  outer  side  of  the  thigh,  passing  down  between  the  vastus 
externns  and  the  biceps,  more  safely  and  more  conveniently 
than  from  any  other  direction.  In  each  case  this  point  must 
be  determined  for  the  case  itself,  but  it  seems  to  me  very  im- 
portant that  this  preparatory  step  should  be  so  taken  that  the 
surface  of  the  involucrum  can  be  freely  exposed.  By  so  doing, 
not  only  does  the  surgeon  give  himself  freedom  in  the  use  of 
his  instruments,  but  he  has  the  opportunity  to  judge  as  to  the 
best  places  and  the  best  manner  of  applying  them. 

Having  exposed  the  involucral  surface,  it  will  generally  be 
found  best  to  enlarge  some  of  the  cloacae,  which  such  an  expos- 
ure reveals,  by  chiselling  or  trephining  the  shell  of  new  bone. 
For  my  own  part,  I  prefer  the  gouge  to  the  trephine,  which 
14 


210 


DISEASES   OF   BONE. 


latter  instrument  I  rarely  use  in  operations  for  necrosis. 
gouge  is  made  large,  with  the  cutting  edge  only  slightly  curved, 
and  terminating  at  right  angles  with  the  side  of  the  instrument, 


Fio.  87. 


which  right  angle  is  slightly  rounded  (Fig.  40),  thus  giving  me  a 
very  delicate  corner  to  work  with,  where  delicacy  is  required, 
and  a  powerful  instrument  where  heavy  cutting  is  to  be  done. 


FIG.  83. 


It  is  well  to  have  several  different  sizes,  and  I  have  found  one 
small  gouge,  with  a  rounded  cutting  edge  and  a  curved  shaft 
(Fig.  42),  very  useful  in  deep  cavities.  Fig.  41  represents  a 


FIG.  89. 


straight-edged  chisel,  which  is  very  useful  in  splitting  or  cut- 
ing  a  firm  bridge  of  bone,  and  is  often  the  only  instrument 
whereby  the  sequestrum  itself,  when  it  is  necessary,  can  be 


FIG.  40. 


G.TIEMANN  &  CO 


divided.     Fig.  43  represents  a  metallic  hammer,  with  its  head 
loaded  with  lead,  which  makes  less  jar  in  striking  on  the  chisel 


NECROSIS. 


211 


than  an  ordinary  hammer,  and  is  much  more  compact  and 
portable  than  any  form  of  mallet.  Fig.  44  represents  a  strong 
elevator,  which  is  used  to  great  advantage  in  separating  the 
tough,  thickened  periosteum  from  the  bone,  and  also  in  loosen- 


FIG.  41. 


ing  and  dislodging  deep  sequestra.  Fig.  39  represents  the 
rongeur,  or  gnawing  forceps,  by  which  small  pieces  of  bone 
can  be  cut  away  at  each  bite  of  the  instrument,  and  thus  the 
involucral  covering  can  be  removed  piecemeal  in  any  direction 


FIG.  42. 


and  to  any  extent.  Figs.  37  and  38  represent  convenient 
forms  of  strong,  long-beaked  forceps  for  removing  sequestra 
from  deep  cavities,  or  through  small  openings  in  the  involu- 
crum. 

FIG.  43. 


These  instruments  are  made,  some  of  them  expressly  for 
me,  by  Messrs.  Tiemann  &  Co.,  to  whom  I  am  indebted  for 
the  illustrations  presented. 


FIG.  44. 


By  these  instruments  sufficient  of  the  shell  is  removed  to 
expose  the  sequestrum,  and  now  an  examination  may  be  made 
by  moving  it  in  various  directions,  to  ascertain  in  which  di- 


212  DISEASES  OF  BONE. 

rection  the  further  cuttings  of  the  involucrum  can  most  ad- 
vantageously be  made.  These  are  then  to  be  continued,  only 
so  far  as  is  necessary  to  liberate  the  dead  bone,  and  no  more, 
for  I  believe  it  is  a  pathological  fact,  well  ascertained,  that  very 
little  restoration  of  removed  involucrum  takes  place,  particu- 
larly in  those  past  the  earliest  youth.  In  this  same  view,  there- 
fore, we  should  be  particularly  careful  not  to  weaken  the  bone 
in  its  transverse  diameter  by  unnecessary  removal,  gaining  the 
required  space,  as  far  as  may  be,  by  longitudinal  rather  than 
by  transverse  ehiseilings.  Having  thus  exposed  the  sequestrum, 
it  may  be  seized  by  forceps,  and,  if  it  be  loose,  it  can  usually 
be  drawn  from  its  bed  through  the  opening  made  by  the  chisel. 
If  it  be  too  long,  or  otherwise  too  large  to  be  thus  extricated, 
the  chiselling  of  the  involucrum  may  be  continued  until  it  is 
released,  or  by  Liston's  bone-forceps  the  sequestrum  may  be 
divided  so  as  to  be  removed  in  two  or  more  pieces.  All  these 
details  must  be  left  to  the  discretion  of  the  surgeon,  he  bearing 
in  mind,  as  cardinal  principles  of  the  operation,  not  to  remove 
any  more  involucrum  than  is  necessary,  and  not  to  mutilate  the 
sequestrum  in  any  such  manner  as  may  prevent  its  entire  re- 
moval. And  here  it  may  be  well  to  put  in  a  word  of  caution. 
!N"o  one  who  has  examined  many  sequestra  can  fail  to  have  ob- 
served how  irregular  their  extremities  are,  and  how  apt  they  are 
to  terminate  in  tine,  delicate  spiculae,  and  sometimes  lamellae, 
which  extend  some  distance  beyond  the  main  mass  of  the 
sequestrum.  These  delicate  prolongations  may,  by  careless 
manipulation,  be  easily  broken  oif,  and  thus  may  be  left  behind 
in  the  most  inaccessible  part  of  the  cavity,  an  accident  care- 
fully to  be  avoided,  by  making  as  little  twisting  or  angular 
movement  of  the  sequestrum  as  possible,  the  surgeon  aiming 
to  draw  it  directly  from  its  bed  rather  than  to  twist  or  pry  it 
out.  After  the  sequestrum  is  thus  removed,  a  careful  exami- 
nation should  be  made  with  the  linger  and  with  the  probe,  to 
make  sure  that  no  fragments  of  dead  bone  be  left  behind. 
Occasionally  we  find  some  sirrall  piece  thus  remaining  deep  in 
the  wound  which  our  forceps  will  not  reach,  and  which  can 
only  be  approached  by  so  serious  an  extension  of  our  incisions 
that  we  hesitate  to  undertake  to  search  for  it.  In  such  cases  it 
is  better  to  leave  the  dead  piece,  after  making  sure  that  there 


NECROSIS.  213 

* 

is  opening  in  the  bone  sufficient  for  its  passage,  trusting  that  it 
will  gradually  be  extruded  by  the  granulations  so  as  either  to 
be  cast  out  or  brought  within  easy  reach  of  the  forceps.  This 
power  of  the  granulations  to  push  a  sequestrum  from  its  bed  is 
seen  not  merely  in  this  disposition  of  small  fragments,  but  also 
in  the  movements  whereby  extensive  sequestra  are  sometimes 
moved  toward  the  surface,  and  are  sometimes  cast  out  alto- 
gether. This  is  in  obedience  to  what  seems  to  be  a  general 
law,  that  all  foreign  bodies  shall  find  their  way  to  the  surface 
of  the  body,  a  law  which  we  see  abundantly  illustrated  in  small 
and  superficial  exfoliations,  and  the  execution  of  which  is  only 
obstructed  in  the  larger  sequestra  by  the  circumstance  of  their 
being  imprisoned  within  an  unyielding  case  of  bone. 

The  wound  should  be  dressed  lightly,  and  allowed  to  granu- 
late. It  is  rarely  worth  while  to  do  more  than  loosely  to  ap- 
proximate the  edges  of  the  incised  integument,  above  and 
below  the  wound,  so  as  to  diminish  the  amount  of  granulating 
surface.  If,  as  is  the  practice  with  some  surgeons,  the  wound 
be  stuffed  full  of  lint,  some  of  it  is  apt  to  get  entangled  in  the 
bony  granulations  as  they  begin  to  spring  up,  and  to  be  diffi- 
cult to  remove.  Some  of  the  lint  also  gets  caught  on  the 
rough  edges  or  surfaces  of  the  chiselled  bone,  and  thus  becomes 
difficult  of  removal.  No  advantage  comes  of  this  packing  of 
lint  into  the  wound,  and  my  own  habit  is  to  spread  three  or 
four  pieces  of  thin  patent  lint  with  cerate,  and  lay  them  lightly 
just  within  the  edges  of  the  wound,  pressing  them  downward 
into  the  cavity,  and  then  laying  charpie  lightly  over  them,  as 
much  as  may  be  necessary  to  fill  out  the  vacuity.  In  this  way 
no  dry  surface  of  lint  comes  in  contact  either  with  bone-granu- 
lations or  with  chiselled  bone,  and  no  annoying  adhesion  of 
the  dressing  will  take  place.  When  suppuration  fairly  begins, 
the  dressings  loosen  easily,  and  are  removed  without  pain,  to 
be  renewed  in  a  similar  manner  as  often  as  the  discharge  makes 
it  necessary,  making  them  lighter  and  smaller  as  the  granula- 
tions diminish  the  suppurating  cavity.  The  wound  usually 
shows  great  activity  in  healing,  and  in  a  few  weeks  is  reduced 
down  to  a  narrow  granulating  line ;  but  we  must  not  be  de- 
ceived. The  cavity  of  the  involucrurn  is  very  loosely  filled 
with  soft  granulations,  and  a  probe  can  still  be  passed  deeply 


214 


DISEASES   OF  BONE. 


into  the  bone.     Indeed,  the  final  filling  up  of  the  involucral 
cavity  is  a  very  slow  process,  and  so,  therefore,  is  the  final 
healing  of  the  wound.     I  have  watched  some  of  my  cases  for 
months,   and  one  case   of  the  tibia  for 
years,  before  the  cavity  was  entirely  closed 
and  the  wound  healed. 

After  cicatrization  is  complete,  a  mod- 
elling process  is  instituted,  which  slowly 
diminishes  the  deformities  caused  by  the 
disease,  and  gives  the  affected  bone  as 
much  shapeliness  as  it  can  receive  after 
so  extensive  destruction.  The  involucral 
enlargement  gradually  diminishes,  the 
roughnesses  and  irregularities  are  smooth- 
ed off,  while  the  cavities  left  by  the  fall 
of  the  sequestrum  are,  to  a  certain  extent, 
filled  up  by  the  granulations.  Usually, 
however,  this  filling  up  is  far  from  com- 
plete, and  a  groove  or  depression,  more  or 
less  considerable,  marks  the  situation  of 
the  cavities,  into  which  depression  the 
cicatrix  sinks.  As  has  been  before  stated, 
these  depressions,  which  are  moderate  in 
the  living  subject,  are  much  deeper  in  the 
macerated  bone,  which  then  shows  that 
very  little  bony  restoration  has  taken 
place,  what  has  been  poured  out  serving 
rather  to  smooth  over  the  irregularities 
of  the  wound  in  the  bone-tissue  than  in 
any  considerable  degree  to  fill  it  up.  Of 
course  in  young  persons,  and  particularly 
in  children,  the  reparation  is  more  perfect.  Fig.  45,  taken 
from  Billroth,  shows  these  changes  two  years  after  the  removal 
of  the  sequestrum. 


FIG.  45.— (From  Bfflroth.) 


PART  II. 
TUMOES    OF    BONE. 


THE  acknowledged  difficulty  of  classifying  diseases  is  met 
with  in  full  force  in  attempting  the  study  of  tumors.  The 
characters,  indeed,  of  well-marked  specimens  are  sufficiently 
distinct  to  make  it  very  easy  to  distribute  them  according  to 
their  easily-recognized  features ;  but  so  many  tumors  present 
uncertain,  irregular,  or  mixed  appearances  and  behavior,  that 
it  becomes  an  extremely  difficult  task  to  arrange  them  in  such 
a  way  as  that  they  shall  fall  naturally  into  classes  sufficiently 
well  characterized  to  be  of  use  in  our  observations  on  the  indi- 
vidual. The  method  adopted  by  modern  pathologists,  of  ar- 
ranging tumors  by  their  anatomical  structure,  is  doubtless  the 
best  and  most  convenient ;  but  the  difficulty  is  only  mitigated, 
not  removed,  and  the  very  accuracy  and  perfection  of  the  mi- 
croscopic diagnosis  show  us  shades  of  difference  which,  while 
they  enlarge  our  knowledge  of  the  individual,  may  seriously 
interfere  with  our  arrangement  of  the  class.  Thus  the  main 
features  of  the  cartilaginous  tumors  of  bone  are  sufficiently 
distinct  to  be  easily  appreciated,  yet  the  microscope  shows  that 
the  cartilaginous  element  puts  on  so  great  a  variety  of  forms 
that  it  is  at  times  hard  to  recognize,  and  often  so  uncertain 
in  its  signification  that  we  sometimes  feel  as  if  the  physical 
qualities  of  a  tumor,  as  perceived  by  the  unaided  eye,  were  a 
more  reliable  test  of  its  character  than  the  minute  dissection 
of  the  microscope.  Again,  the  anatomical  characters  are  not 
always  the  same  in  all  parts  of  the  same  tumor.  We  may 


216  TUMORS  OF  BONE. 

have  cartilage  in  one  part,  bone  in  another,  and  unequivocal 
cancer  in  another,  in  tumors  which  present  nothing,  in  their 
history  or  appearance  to  the  eye,  that  indicates  the  reason  of 
the  difference  in  their  several  parts.  Still  further,  their  con- 
stituent elements  undergo,  in  some  instances,  changes  so  dis- 
tinct and  so  complete  that  it  is  fair  to  say  that  a  fibrous  or 
cartilaginous  tumor  is  converted  into  a  bony  tumor ;  a  cyst,  by 
proliferation,  is  changed  into  a  solid  tumor ;  or  either  of  them 
may  be  converted  into  a  malignant  form,  and,  after  perhaps 
years  of  slow,  benignant  growth,  may  put  on  the  rapidly-de- 
structive features  of  the  encephaloid.  It  is  evident  that  these 
considerations  must  make  a  strict  classification  impossible,  if 
we  expect  from  it  an  arrangement  by  which  every  tumor  shall 
be  assigned  to  its  proper  position,  and  each  division  shall  have 
its  exact  and  proper  limits,  into  which  each  individual  shall,  by 
virtue  of  its  anatomical  construction,  be  received.  "We  must 
perforce  be  content,  therefore,  with  using  such  classification  as 
we  may  adopt,  only  with  a  view  to  the  convenience  and  assist- 
ance it  may  afford  us  in  describing  and  studying  individual 
cases,  without  relying  too  much  upon  it  as  stamping  each  speci- 
men with  marks  which  shall  be  so  unmistakable  that  we  can 
at  once  assign  to  it  its  place  in  the  catalogue,  and  thereby  be 
saved  the  necessity  of  investigating  its  individual  peculiarities 
and  dispositions.  Used  in  this  way,  we  shall  find  the  classifi- 
cation now  commonly  adopted,  by  which  tumors  are  arranged 
according  to  their  anatomical  structure,  to  be  the  best  and  most 
convenient  we  can  use,  and  one  which  will  perhaps  serve  us 
better  than  any  other  in  our  study  of  individual  specimens. 

The  arrangement  usually  adopted  by  writers  is  a  division 
into — 

1.  Cartilaginous  tumors. 

2.  Osseous  tumors. 

3.  Fibrous  and  fibroid  tumors. 

4.  Myeloid  tumors. 

5.  Vascular  and  pulsating  tumors. 

6.  Cystic  tumors. 

7.  Malignant  tumors. 

These  principal  classes  embrace  many  subdivisions,  and  in 
treating  of  them  I  shall  not  always  strictly  adhere  to  the  order 


CARTILAGINOUS  TUMORS.  217 

in  which  they  are  here  placed,  departing  from  that  order,  how- 
ever, only  when,  for  the  sake  of  clearness,  it  seems  more  con- 
venient to  arrange  them  into-somewhat  different  groups. 


CHAPTER  I. 

CARTILAGINOUS   TUMORS. 

CARTILAGINOUS  tumors  are  characterized,  as  a  class,  by  their 
possessing  the  anatomical  elements  of  cartilage.  In  a  very 
large  proportion  of  these  tumors,  the  microscopical  elements 
are  identical  with  those  of  the  normal  cartilage ;  in  some,  how- 
ever, they  depart  from  the  normal  type,  presenting  many  vari- 
eties, sometimes  leaving  much  doubt  as  to  their  nature.  One 
chief  circumstance,  which  may  be  noticed  as  characteristic  of 
this  tumor,  is  the  great  diversity  of  microscopic  forms  which 
each  specimen,  in  its  different  portions,  may  present.  Mr. 
Paget,  on  this  point,  remarks  :  "  This  diversity  of  microscopic 
forms  is  enough  to  baffle  any  attempt  to  describe  them  briefly, 
or  to  associate  them  with  any  corresponding  external  charac- 
ters in  the  tumors.  The  most  diverse  forms  may  even  be  seen 
side  by  side  in  the  field  of  the  microscope.  But  this  diversity 
is  important.  It  has  its  parallel,  so  far  as  I  know,  in  no  other 
innocent  tumor ;  and  the  cartilaginous  tumors  form,  perhaps, 
the  single  exception  to  a  very  generally  true  rule,  enunciated 
by  Bruch,  namely,  that  it  is  a  characteristic  of  the  cancerous 
tumors,  and  distinctive  between  them  and  others,  that  they 
present,  even  in  one  part,  a  multiformity  of  elementary  shapes." 
Mr.  Paget,  in  his  excellent  chapter  on  cartilaginous  tumors, 
from  which  the  above  extract  is  taken,  gives  a  full  account  of 
the  varieties  he  noticed  in  the  careful  microscopic  examination 
of  fifteen  specimens.  His  general  conclusions  are,  that  the 
variations  are  shown  in  the  basis  or  intercellular  substance,  in 
the  cartilaginous  cells,  and  in  their  nuclei.  First,  in  the  inter- 
cellular substance,  he  remarks  that  it  varies  in  quantity,  some- 
times being  largely  in  excels,  with  very  few  cells  scattered 
through,  and  sometimes  in  small  quantity,  with  a  great  pre- 


218 


ponderance  of  cells,  which  seem  to  make  up  the  whole  mass 
of  the  tumor.  It  varies  also  in  consistence,  sometimes  firm, 
and  sometimes  very  soft ;  and  in  texture,  some  specimens  hav- 
ing a  transparent,  almost  structureless  basis,  while  the  most 
present  more  or  less  distinct  evidence  of  a  fibrous  plan,  the 
fibres  differing  not  a  little  among  themselves,  in  their  shape, 
size,  distinctness,  and  arrangement  about  the  cells.  The  carti- 


FIG.  46.— (From  Paget.) 


FIG.  47.— (From  Paget.) 


lage  cells  themselves  vary  also  very  greatly.  Sometimes  they 
are  large  and  abundant,  sometimes  few  and  small;  some  have 
the  rounded  shape  of  the  normal  cartilage-cell,  and  some  dif- 
fer widely  from  them.  Sometimes  their  outline  is  dark  and 


w 

FIG.  48.— (From  Paget.) 


FIG.  49.— (From  Paget.) 


distinct,  sometimes  so  faint  as  to  be  almost  imperceptible,  and 
occasionally  there  seems  to  be  no  cell-wall  at  all,  the  nuclei 
being  embedded  in  the  hyaline  substance  without  any  cell-en- 
closure. The  nuclei  also  present  many  varieties.  Sometimes 


CARTILAGINOUS   TUMORS. 


219 


they  are  single,  sometimes  two  or  more  are  seen,  and  these 
apparently  acquiring  for  themselves  the  character  of  primary 
cells.  Sometimes  they  show  nucleoli,  often  they  do  not  (Figs. 
46,  47,  48,  49).  Some  are  small,  round,  and  clear  in  outline, 


FIG.  50.— (From  Paget) 


Fis.  51.— (From  Paget.) 


others  are  large,  pale,  and  indistinct ;  some  are  granular,  and 
some  show  globules  of  oil  in  their  interior.  The  most  marked 
deviation  from  the  usual  appearance  of  the  nuclei  is  that  in 
which  they  present  an  irregular  branching  outline  very  much 


s 


FIG.  52.— (From  Cornil  and  Eanvier.) 


resembling  the  shape  of  the  bone-corpuscle  (Figs.  50,  51,  52). 
This  is  so  common  that  Mr.  Paget  noticed  it  in  seven  of  his 
cases ;  and  although  he  does  not  admit  that  it  is  any  indication 
of  a  commencement  of  a  process  of  ossification,  yet,  in  view  of 


220  TUMORS  OF  BOXE. 

the  well-known  fact  that  these  tumors  have  a  great  propensity 
to  ossify,  it  would  seem  reasonable  to  suppose  that  this  striking 
change  was  one  of  its  earliest  manifestations,  and  not  unphilo- 
sophical  to  assume  that  it  was  so,  in  the  absence  of  positive 
evidence  that  it  was  not.  In  fact,  Mr.  Queckett,  in  his  lec- 
tures on  histology,  adopts  this  view  of  their  nature.  Making 
all  due  allowances,  however,  for  these  various  deviations,  the 
fact  still  remains  that  this  class  of  tumors  is  characterized  by 
anatomical  features  which  are,  in  the  main,  identical  with 
those  of  normal  cartilage ;  an  identity  which  their  clinical  his- 
tory very  strongly  confirms. 

The  causes  of  these  growths  cannot  often  be  discovered. 
They  do  occasionally  seem  to  arise  from  an  injury,  though  not 
more  frequently  than  other  forms  of  tumor.  A  case,  recently 
amputated  at  Bellevue  Hospital,  commenced  in  a  finger,  appar- 
ently in  consequence  of  a  bruise  against  the  mantel-piece.  They 
commence  their  growth  most  commonly  in  childhood  and  early 
youth,  though  instances  are  recorded  where  they  have  made  their 
first  appearance  in  old  age.  Their  growth  is  painless,  and  com- 
monly quite  slow,  though  in  exceptional  instances  a  rapid  rate 
of  increase  is  observed.  This  more  rapid  development  is  usually 
connected  with  softness  of  texture,  and  a  great  preponderance 
of  cell -formation,  and  is  very  constantly  observed  in  the  recur- 
rent tumors  after  removal.  In  their  usual  demeanor  they  are 
undoubtedly  benign,  and  when  once  thoroughly  removed  they 
are  not  likely  to  reappear.  But  here,  again,  as  in  fibrous  and 
certain  other  tumors,  we  find  sometimes  a  disposition  to  return 
after  removal,  and  to  involve  new  and  distant  parts,  and  finally, 
to  destroy  life  by  their  more  and  more  extensive  encroachments, 
which  gives  them  the  malignant  character  which  their  histolo- 
gical  examination  cannot  explain.  On  the  other  hand,  if  the 
removal  be  not  complete,  the  disease  will  certainly  grow  again, 
though  sometimes  not  till  after  a  long  interval.  I  removed  the 
finger  of  a  man  from  whom  Mr.  Cusack,  of  Dublin,  had,  nearly 
twenty  years  before,  cut  out  a  cartilaginous  growth,  which  sprang 
from  the  surface  of  the  first  phalanx,  and  which  had  remained 
well  for  many  years,  and  then  gradually  grew  again  to  a  size 
greater  than  that  of  the  original  tumor ;  but  yet  which  presented 
no  other  anatomical  characters  than  those  of  normal  cartilage. 


CARTILAGINOUS   TUMORS. 


221 


But  there  is  another  point  in  the  pathological  history  of  these 
tumors  which  is  too  well  ascertained  to  be  passed  by  without  no- 
tice, that  is,  their  relation  to  malignancy.  It  is  difficult,  in  any 
case,  to  prove  that,  in  a  given  growing  tumor,  a  change  conies 
over  its  anatomical  constituents,  whereby  it  assumes  the  charac- 
ter of  malignancy  which  originally  it  had  not ;  but  is  it  certain 
that  tumors  which,  in  every  mark  and  sign,  gave  evidence  of 
being  simple  cartilaginous  tumors,  have,  after  a  longer  or  short- 
er period  of  slow  and  painless  increase,  such  as  characterizes  the 
development  of  benignant  growths,  taken  on  a  more  active, 
rapid,  and  destructive  behavior,  and  terminated  with  all  the  in- 
dications of  the  most  virulent  malignancy  ?  .  But,  still  more,  the 
cartilaginous  is  sometimes  mingled  with  the  cancerous  element 
in  the  same  tumor.  Of  this  Mr.  Paget  gives  a  well-marked  ex- 
ample in  a  tumor  of  large  size  which  was  taken  from  the  front 
of  the  lumbar  vertebrae  (Fig.  53).  In  this  case  the  two  elements 


FIG.  53.— (From  Paget.) 

were  mingled  in  an  irregular  manner,  each  lobule  retaining  its 
peculiar  characteristics,  and  about  in  the  proportion  of  half-and- 
half.  This  I  suppose  to  be  a  rare  specimen,  but  it  illustrates, 
in  a  remarkable  manner,  the  affiliation  between  cartilaginous 
growth  and  cancer,  while  at  the  same  time  it  presents  them  as 


222 


TUMORS   OF  BOXE. 


essentially  distinct  formations,  and  maintaining  that  distinction 
even  when  combined  in  a  tumor  which  was  far  advanced  in  its 
development.  Mr.  Paget  also  alludes  to  another  case,  where 
cartilage  and  medullary  cancer  were  associated  in  a  tumor  of 
the  testicle,  wh&h  had  been  growing  about  eighteen  months. 
Yirchow  and  several  other  writers  have  described  similar  com- 
binations. 

The  size  which  these  tumors  sometimes  attain  is  extraordi- 
nary, surpassing  those  of  any  other  formation,  if,  perhaps,  we 
except  the  fibrous.  Mr.  Paget  speaks  of  one  which  he  saw  in 
St.  Bartholomew's  Hospital,  in  which,  "  within  three  months 
of  his  £rst  noticing  it,  a  cartilaginous  tumor  increased  to  such 


FIG.  54.— (From  Paget ) 


an  extent  that  it  appeared  to  occupy  nearly  the  whole  length 
of  his  thigh,  and  was  as  large  round  as  my  chest."  He  men- 
tions another,  amputated  by  Mr.  Frogley,  in  which  the  tumor 
extended  from  the  knee-joint  to  within  an  inch  of  the  trochan- 
ters,  and  measured  nearly  three  feet  in  circumference.  Sir 


CARTILAGINOUS  TUMORS.  223 

Philip  Crampton's  case,  however,  surpasses  all  others  that  I  have 
seen  recorded.  In  this  remarkable  case,  a  cartilaginous  tumor 
of  the  thigh  was  six  feet  and  a  half  in  circumference,  being, 
therefore,  a  little  more  than  two  feet  in  diameter.  Fig.  54, 
taken  from  Paget,  gives  a  good  idea  of  the  general  features  of  a 
large  cartilaginous  tumor  growing  from  the  upper  part  of  the 
humerus.  It  was  nearly  thirty  inches  in  circumference.  The 
specimen  is  in  the  museum  of  the  College  of  Surgeons. 

The  changes  that  cartilaginous  tumors  may  undergo,  form 
an  important  and  characteristic  part  of  their  history.  These 
changes  can  hardly  be  looked  upon  as  representing  a  definite 
tendency  which  will  be  realized  more  or  less  completely  in 
every  specimen.  Rather,  they  must  be  considered  as  excep- 
tional and  accidental,  as  the  fact  is,  that  unchangeableness  is 
almost  as  characteristic  of  the  cartilaginous  as  of  the  bony,  or 
even  the  fibrous,  or  fatty  tumor.  But,  nevertheless,  changes  are 
noticed  so  often  as  to  require  a  special  study  both  anatomical 
and  clinical,  if  we  would  understand  all  that  we  should  know 
about  them.  Thus  we  have  first  a  softening.  Sometimes  the 
whole  tumor,  as  it  grows  larger,  grows  softer ;  indeed,  this  is 
the  usual  fact,  particularly  where  the  increase  in  size  is  rapid, 
and  has  its  parallel  in  many  other  hard  tumors,  which,  as  they 
grow  larger,  are  apt  to  become  softer.  This  change,  however, 
does  not  seem  to  be  necessarily  connected  with  any  alteration 
of  structure,  and  perhaps  may  be  explained  by  the  greater  suc- 
culence and  looser  texture  which  the  growing  mass  assumes. 
There  is  another  form  of  softening,  where  the  alteration  begins 
in  the  central  parts  of  the  tumors,  and  gradually  involves  their 
substance,  until  a  large  part  of  the  mass  has  undergone  the 
change,  while  perhaps  the  most  superficial  portions  still  maintain 
their  original  appearance  and  structure.  This  central  softening 
is  sometimes  so  complete  that  the  whole  tumor  is  involved,  leav- 
ing only  a  thin  superficial  layer  of  unchanged  material,  and  giv- 
ing a  cystic  character  to  the  tumor,  which  becomes  more  striking 
as  the  wall  becomes  thinner,  and  the  central  parts  more  fluid. 
In  most  cases,  the  softened  portions  of  the  tumor  assume  the 
appearance  of  greater  translucency  and  clearness,  so  that  they 
have  been  likened  to  fresh  fish-flesh,  or  even  to  jelly.  When 
they  have  become  so  soft  as  to  be  fluid,  the  appearance  is  often 


224  TUMORS  OF  BOXE. 

likened  to  honey,  and,  when  this  honey-like  material  is  distrib- 
uted about  the  mass  in  many  small  cells  or  cysts,  the  appear- 
ances are  strongly  suggestive  of  colloid. 

But  there  is  another  mode  of  softening,  which  is  more  seri- 
ous, inasmuch  as  it  commonly  involves  the  commencement  of  a 
process  of  destruction.  This  may  begin  with  a  process  of  inflam- 
mation, or  may  be  a  rapid  softening,  to  which  inflammation  is 
afterward  superadded.  Examined  in  the  earlier  stage,  the  part 
shows  broken-down  tissue,  degen crating  fibrine,  blood-corpuscles, 
and  pus-cells,  variously  intermingled.  The  products  of  inflam- 
mation collect  in  a  focus,  forming  a  sort  of  abscess  which  breaks 
and  discharges  its  contents.  Ulceration  now  begins,  sometimes 
with  sloughing,  and  we  have  imitated  in  all  respects  the  behav- 
ior of  the  most  malignant  growths,  an  imitation  which  is  carried 
out,  unfortunately,  through  all  the  worst  and  most  destructive 
phases  of  malignant  disorganization.  I  do  not  pretend  to  say 
that  such  a  process  may  not  in  some  cases  terminate  in  simple 
destruction  of  the  growth  and  be  followed  by  a  proper  healing 
process,  but  it  must  be  confessed  that,  when  such  action  is  ob- 
served in  a  cartilaginous  tumor,  the  reasonable  apprehension  is, 
that  the  ill  behavior  is  indicative  of  ill  character,  and  that  the 
originally  benign  tumor  has  assumed  the  nature  as  well  as  the 
behavior  of  a  malignant  growth,  and  will  probably  vindicate  its 
claims  to  be  so  considered  by  ultimately  destroying  the  patient. 

Again,  we  have  a  change  into  bone.  This  change,  from  the 
well-known  relations  of  cartilage,  might  be  considered  as  the 
natural  one,  and  might  be  expected  to  be  frequent.  Some  de- 
gree of  it  is  not  rare,  and  yet  it  would  not  be  correct  to  repre- 
sent the  ossific  change  as  very  common.  It  presents  itself  un- 
der two  principal  varieties :  First,  in  a  cartilaginous  tumor 
growing  on  a  bone,  we  may  have  the  ossification  shooting  out 
from  the  original  bone,  and  gradually  encroaching  upon  the 
tumor,  until  it  is  more  or  less  largely  converted  into  a  bony 
mass ;  or,  secondly,  we  may  have  ossification  commencing  in 
the  centre  of  the  tumor,  or  in  many  detached  centres,  and  these 
centres  may  gradually  increase  until  they  coalesce  into  one. 
Many  examples  are  seen  of  both  these  methods  of  ossification, 
and  it  is  not  uncommon  to  find  them  combined  in  one  speci- 
men. Sometimes  the  process  is  limited  and  imperfect,  and  then 


CARTILAGINOUS   TUMORS.  225 

we  have  small  bony-spiculae  shooting  into  the  tumor,  or  small 
isolated  masses  scattered  through  it,  or  sometimes  the  process 
is  more  energetic  and  determined,  and  we  have  the  whole  mass 
converted  into  solid  bone.  The  quality  of  the  newly-formed 
bone  varies  much ;  sometimes  being  a  mere  amorphous  calca- 
reous infiltration,  but  often  presenting  every  feature  of  the  most 
perfectly-formed  bone,  so  perfect  that  we  cannot  trace  in  its  ex- 
ternal features  or  in  its  microscopical  characters  any  difference 
between  the  original  and  the  morbid  formations. 

In  a  certain  number  of  cases,  the  ossification  of  the  tumor 
commences  so  early  in  its  history,  and  proceeds  so  regularly  as 
the  tumor  grows,  as  strongly  to  impress  us  with  the  idea  that  it 
is  the  normal  progress  of  the  disease,  in  which,  after  a  certain 
period  of  cartilaginous  existence  is  passed  through,  the  structure 
is  gradually  replaced  by  bone,  by  virtue  of  a  continuation  of  the 
same  forces  which  formed  the  original  tumor.  The  behavior 
of  these  tumors  seems  very  much  the  same  as  the  actions  which 
take  place  in  normal  development  in  the  cartilaginous  extremi- 
ties of  the  long  bones  in  the  child,  the  original  layers  of  the 
new  growth  becoming  ossified  while  new  layers  of  cartilage  are 
forming  on  their  surface.  So  definite  and  orderly  is  this  dispo- 
sition, that  it  is  not  easy  in  every  case  to  decide  whether  the 
tumor  should  be  considered  as  a  cartilaginous  growth  ossifying, 
or  an  osseous  growth  developed  in  cartilage.  Hence,  several 
of  the  older  writers,  and  more  lately  Follin,  have  made  a  new 
class  of  these  cases,  and  have  studied  them  under  the  name  of 
osteo-cartilaginous  tumors.  There  seems  to  be  some  reason  for 
this  subdivision,  and  perhaps  some  practical  advantages  may 
arise  out  of  it.  The  following  case  presents  a  striking  example 
of  these  peculiar  features.  I  publish  it  here  by  permission  of 
my  friend  Dr.  Yan  Buren,  in  whose  practice  it  occurred,  and 
by  whose  kindness  I  saw  the  patient  at  several  periods  of  his 
history : 

Elijah  Vandenhoof,  of  ISTew  Jersey,  of  good  constitution,  aged 
forty-three,  came  under  Dr.  Yan  Buren' s  care  in  May,  1818, 
with  an  immense  tumor,  involving  the  lower  half  of  the  femur 
of  the  left  side.  About  twenty  years  before,  he  had  wrenched 
the  left  knee  in  wrestling,  and  some  three  months  after  this 
accident  he  first  noticed  a  swelling  about  the  knee-joint,  which 
15 


226  TUMORS  OF  BONE. 

has  since  slowly  increased  in  size,  gradually  extending  up  the 
thigh.  At  this  time,  the  tumor  involved  the  whole  circumfer- 
ence of  the  limb,  extending  from  the  knee-joint  upward  as  far 
as  the  middle  of  the  femur ;  it  was  immovably  connected  with 
the  bone,  and  measured  twenty-eight  inches  in  circumference. 
On  its  anterior  aspect  it  was  generally  spherical  in  shape,  with 
very  slight  irregularities  on  its  surface ;  posteriorly  it  was  very 
irregular  and  craggy,  presenting  several  hard,  projecting,  knobby 
eminences.  It  had  everywhere  the  feel  of  bone  covered  with 
a  thin  layer  of  tissues.  It  was  not  tender  to  the  touch,  although 
there  was  a  point  where  the  skin  had  recently  assumed  a  dusky- 
red  appearance,  which  caused  some  complaint,  apparently  the  re- 
sult of  simple  tension  of  the  integuments.  There  were  no  large 
veins  observable  on  its  surface.  The  tumor  was  more  prominent 
on  the  posterior  aspect  of  the  limb  than  elsewhere,  and  seemed 
to  terminate  abruptly  about  six  and  a  half  inches  above  the 
condyles  of  the  femur ;  anteriorly  it  shelved  oif  more  gradually, 
and  extended  apparently  some  four  inches  farther  upward.  The 
knee-joint  was  but  slightly  movable,  but  its  motions  were  not 
accompanied  with  pain.  During  the  present  year  he  had  suf- 
fered almost  constantly  with  a  dull,  aching  pain  in  the  tumor, 
which  was  invariably  more  severe  at  night  and  in  damp  weather. 
This  pain  seemed  to  be  gradually  increasing  in  intensity,  and 
had  of  late  deprived  him  of  sleep  and  diminished  his  appetite. 
He  was  also  losing  flesh,  and  had  a  pulse  more  frequent  than 
natural.  The  limb  was  amputated  at  about  the  middle  of  the 
femur,  on  the  20th  of  May,  and  the  amputation  was  followed 
by  a  rapid  recovery. 

"  The  tumor,  on  examination,  presented  a  magnificent  speci- 
men of  true  osteo-cartilaginous  exostosis.  Its  periphery  was 
everywhere  covered  by  a  layer  of  fibro-cartilagirious  material, 
varying  in  thickness  from  a  line  to  more  than  half  an  inch,  fill- 
ing up  its  anfractuosities,  and  giving  it  a  much  more  uniform 
appearance  than  it  has  at  present  after  maceration.  It  is  now 
exceedingly  irregular  in  outline,  covered  by  rounded  knobs  and 
craggy,  stalactiform  projections.  The  condyles,  it  will  be  seen, 
participate  in  the  alteration.  The  weight  of  the  tumor,  when 
recent,  was  thirteen  pounds.  The  soft  parts,  covering  the  bony 
mass,  were  to  all  appearance  perfectly  healthy,  with  the  excep- 


CARTILAGINOUS  TUMORS.  227 

tion  of  the.  alteration  consequent  upon  the  pressure  of  the  tu- 
mor, and  their  change  of  position.  The  nervous  trunks,  par- 
ticularly the  popliteal  and  peroneal  prolongations  of  the  sciatic, 
were  observed  to  be  thicker  than  natural,  and  had  evidently,  by 
their  elongation,  been  subjected  to  very  considerable  stretch- 
ing." 

In  July,  1849,  some  signs  of  a  return  of  the  disease  began 
to  manifest  themselves,  in  the  shape  of  pain  in  the  stump  and 
an  enlargement  of  the  sawed  end  of  the  bone.  These  slowly 
increased,  his  health  began  to  fail,  and  on  the  21st  of  March, 
1850,  it  was  deemed  best  to  endeavor  to  remove  the  whole  dis- 
ease by  amputation  at  the  hip-joint.  This  was  done  by  Dr. 
Yan  Buren,  by  the  method  of  the  anterior  and  posterior  flaps. 
The  patient  made  a  most  satisfactory  recovery. 

"  The  specimen,  previous  to  dissection,  was  successfully  in- 
jected by  my  friend  Dr.  Isaacs,  to  whose  kindness  I  am  indebt- 
ed for  its  preparation.  It  will  be  perceived  that  the  appearance 
of  the  disease  corresponds  with  the  description  given  already 
of  the  tumor  first  removed.  It  is  of  a  uniform  bony  hardness, 
and  very,  irregular  outline,  involving  the  lower  end  of  the  bone, 
and  extending  upward  toward  the  trochanter.  One  spicular 
prolongation,  projecting  toward  the  joint,  on  its  anterior  sur- 
face, was  grazed  by  the  knife  in  cutting  out  the  anterior  flap  ; 
had  this  flap  been  half  an  inch  longer,  the  knife  would  have 
been  caught  behind  this  bony  projection,  and  the  operation 
unavoidably  delayed.  This  danger  was  partially  recognized 
beforehand.  As  this  specimen  has  been  preserved  in  the  wet 
state,  the  layer  of  the  fibro-cartilage  on  the  surface  of  the  bone 
can  be  recognized.  In  removing  the  layer  of  muscles  covering 
the  disease,  it  was  noticed  that  the  sartorius  and  rectus,  and 
most  of  the  adductor  group,  were  closely  attached,  by  their  cut 
extremities,  to  the  enlarged  bone ;  the  first-mentioned  muscle 
was,  in  fact,  inserted  by  a  well-marked  tendon,  and  was  noticed 
before  the  operation  to  act  strongly  as  a  flexor  of  the  stump. 
The  muscles  had  preserved  their  volume  fairly,  although  they 
had  evidently  undergone  some  degree  of  fatty  atrophy.  The 
femoral  artery  was  pervious,  and  apparently  of  full  size,  up  to 
a  point  about  two  inches  from  the  extremity  of  the  bone,  where 
it  became  transformed  into  a  fibrous  cord.  The  sciatic  nerve 


228  TUMORS  OF  BOXE. 

was  considerably  enlarged,  particularly  at  its  extremity,  where 
it  is  closely  adherent  to  the  surface  of  the  bone — occupying,  as 
it  were,  a  valley  between  two  projecting  crags  of  bone,  by  the 
growth  of  which  it  was  constantly  subjected  to  increasing  press- 
ure. This  was  the  spot  upon  the  stump  to  which  most  of  the 
pain  was  attributed." 

The  patient,  after  his  recovery  from  the  amputation,  re- 
turned to  the  country,  where  he  enjoyed  excellent  health  for 
about  two  years.  He  then  began  to  suffer  pain  in  the  stump, 
which  increased  for  several  months,  and  finally  brought  him  to 
town  again  for  advice.  Dr.  Van  Buren  recognized  a  return  of 
the  bony  growth  in  the  os  innominatum,  of  the  side  from  which 
the  lower  extremity  had  been  removed,  involving  the  acetabu- 
luni  and  the  neighboring  parts.  This  continued  slowly  to  in- 
crease, causing  pain  similar  in  character  to  that  formerly  experi- 
enced. Finally  symptoms  indicating  pressure  upon  the 'rectum 
and  bladder  gradually  appeared,  and  increased  in  severity  until 
death  followed,  at  the  end  of  five  years  from  the  date  of  the  last 
operation,  from  intestinal  obstruction,  resulting  from  pressure 
of  the  intra-pelvic  growth  upon  the  rectum.  The  parts  were 
removed  after  death,  and  sent  to  the  city  for  inspection.  "  The 
whole  os  innominatum  was  involved  in  an  enormous  outgrowth 
similar  in  character  to  those  already  described,  presenting  no 
new  appearances  which  could  be  recognized  as  malignant." 
The  physician  who  made  the  autopsy  reported  that  there  were 
no  evidences  of  disease  in  any  other  organs  of  the  body,  the 
immediate  cause  of  death  being  peritonitis. 

This  case  offers  a  good  example  of  that  semi  -  malignant 
behavior  in  which,  though  no  proper  cancerous  character  is 
assumed  by  the  growth,  and  though  no  evidence  is  discovered 
of  generalization  of  the  disease,  yet,  by  its  recurrence  and  ex- 
tensive invasion  of  vital  parts,  it  finally  produces  death,  and 
this  after  what  seems  to  be  the  most  complete  removal.  Fig. 
55  shows  the  appearance  of  both  portions  of  the  femur  after 
maceration. 

Another  quite  interesting,  and  not  very  uncommon,  form 
of  osteo-cartilaginous  growth  is  that  which  affects  the  last  pha- 
lanx of  the  great-toe.  It  springs  from  the  dorsal  surface  of  the 
phalanx,  under  the  nail.  As  it  grows — and  the  growth  seems 


CARTILAGINOUS   TUMORS. 


229 


to  be  by  cartilage  which  ossifies  as  it  grows — it  is  pushed  for- 
ward by  the  resistance  of  the  nail,  and  makes  its  appearance 
just  under  the  free  portion  of  the  nail,  as  a  hard,  wart-like 
growth,  insensible  to  the  touch,  and  usually  painless,  when  not 
pressed  upon,  but  giving  rise  to 
a  great  deal  of  pain  and  tender- 
ness when  pressed  upon  by  the 
shoe  in  walking. 

The  first  case  of  this  curious 
affection  that  I  saw  was  in  the 
New  York  Hospital,  in  the  ser- 
vice of  my  friend  and  preceptor, 
Dr.  Buck.  I  give  it  in  his  own 
words  : 

"  William  Jewell,  aged  twen- 
ty, Norway,  was  admitted  into 
the  New  York  Hospital,  Sep- 
tember 25,  1839.  Fourteen 
months  ago,  first  felt  pain  in  the 
great-toe  of  the  right  foot  under 
the  nail.  Had  walked  about 
with  a  pair  of  new  boots,  which 
were  rather  small.  Upon  exami- 
nation found  a  small,  hard  lump 
growing  under  the  free  edge  of 
the  nail ;  this  he  kept  pared 
close  with  his  razor,  which  of- 
ten caused  it  to  bleed  freely. 
Eight  months  ago  it  was  par- 
tially removed  with  a  portion 
of  the  nail,  but  soon  after  the 
wound  healed  it  grew  out  again. 
September  25th  it  presented 
the  following  appearances :  The 
edge  of  the  nail  was  pared 
short,  so  that  a  small  tumor  pro- 
truded anterior  to  it,  of  about  the  size  of  a  split  pea,  of  a  gray- 
ish rose-color,  tough  and  dense,  though  not  having  the  feeling 
of  an  osseous  growth,  free  from  pain.  He  always  took  the  pre- 


FIG.  55.— (From  Van  Buren's  Collection.) 


230  TUMORS  OF  BONE. 

caution  to  wear  an  easy  boot,  otherwise  lie  felt  uneasiness. 
From  its  apparent  situation,  anterior  to  the  nail,  I  aimed  to 
save  the  nail,  and  passed  a  bistoury  down  through  the  nail,  a 
little  behind  its  middle,  in  a  transverse  direction,  to  the  bone, 
then  directed  its  edge  forward,  grazing  the  bone  so  as  to  re- 
move the  tumor  at  its  origin,  where  it  was  evidently  of  an  osse- 
ous character,  requiring  much  force  to  cut  through  it.  This 
incision,  I  found,  split  down  through  the  middle  of  the  excres- 
cence. I  therefore  determined  to  remove  the  entire  nail ;  and, 
in  the  same  manner  as  above,  commenced  a  new  incision,  two 
lines  posterior  to  the  union  of  the  nail  and  cuticle,  going  down 
to  the  bone,  and  grazing  its  upper  surface  as  before,  where  the 
tumor  grew  from  the  bone.  I  pared  away  the  surface  as  close  as 
possible.  The  haemorrhage  was  trifling,  color  of  bone  healthy, 
The  resistance  of  the  nail  had  given  a  direction  forward  to  the 
excrescence,  and  thus  deceived  me  as  to  its  point  of  origin, 
which  was  beneath  the  middle  of  the  nail.  Simple  dressings 
to  the  wound. 

"  October  21s£. — The  wound  gradually  cicatrized  under  the 
application  of  light  dressings,  with  the  occasional  application 
of  nitrate  of  silver  to  repress  the  exuberant  granulations.  It 
had  diminished  to  the  size  of  a  split  pea,  without  any  appear- 
ance of  reproduction,  when  at  his  urgent  request  he  was  dis- 
charged. A  small  portion  of  nail  grew  out  of  the  posterior 
corner,  which  had  escaped  the  knife." 

Some  years  after,  another  case  presented  itself  to  me,  in 
private  practice,  which  I  had  the  opportunity  of  watching  after 
the  cure.  Mr.  George  H.  P.,  aged  about  thirty,  showed  me  in 
December,  1855,  a  small  corn-like  projection,  under  the  nail  of 
the  great-toe  of  his  left  foot,  which  had  made  its  appearance 
some  five  months  previously,  after  having  worn  for  some  time 
a  boot  which  was  too  short  for  his  foot.  It  had  given  him  a 
good  deal  of  trouble  whenever  he  walked  far,  and  particularly 
if  he  wore  a  boot  in  the  least  degree  too  tight ;  and  whenever 
he  stubbed  his  toe,  or  received  any  blow  upon  it,  the  pain  was 
excessive.  The  projection  was  a  little  to  the  inside  of  the 
median  line  of  the  toe,  and  was  only  partly  covered  by  the  nail, 
from  under  which  it  protruded,  and  by  which  it  was  evidently 
compressed.  On  feeling  it,  I  recognized  a  hardness  about  the 


CARTILAGINOUS  TUMORS.  231 

base  of  the  little  tumor,  which,  taken  in  connection  with  its 
seat  and  history,  induced  me  to  regard  it  as  a  subungual  exos- 
tosis.  Unwilling  to  inflict  an  operation  for  so  slight  an  affec- 
tion, I  tried  for  some  weeks  the  effect  of  removing  all  pressure 
of  the  boot,  and  at  the  same  time  I  destroyed,  with  liquor 
potassse,  the  thickened,  wart-like  cuticle  which  covered  the 
deeper-seated  tumor  of  the  bone.  As  the  flakes  of  altered 
cuticle  separated,  and  were  drawn  out  from  under  the  nail, 
some  temporary  relief  would  be  obtained,  from  the  pressure 
being,  by  so  much,  diminished.  They  formed  again  rapidly, 
however,  and,  as  the  tumor  itself  was  all  the  time  slowly  increas- 
ing and  becoming  more  sensitive,  it  was  deemed  best  to  remove 
it.  The  operation  was  performed  on  the  22d  of  March,  1856. 
An  incision  was  made  around  the  whole  nail,  about  a  line  dis- 
tant from  its  margins,  taking  care  to  go  far  enough  back  to 
include  the  whole  matrix,  and  far  enough  forward  to  include 
the  tumor.  By  this  incision  the  whole  nail  and  the  soft  parts 
under  it  were  raised  from  the  upper  surface  of  the  phalanx,  and 
the  tumor  of  course  fully  exposed.  It  was  found  to  spring 
from  the  bone  near  its  extremity,  and  sufficient  sound  bone  re- 
mained to  warrant  me  in  cutting  off  the  anterior  half  of  the 
phalanx  only.  This  was  easily  done  by  the  bone-nippers.  A 
flap  was  thus  left  which  was  a  little  longer  than  was  necessary 
to  cover  the  end  of  the  bone.  This  flap  was  simply  drawn  a 
little  up  toward  the  top  of  the  phalanx,  and  the  gap  thus  left 
was  allowed  to  heal  by  granulation.  The  healing  process  went 
on  most  favorably,  and  was  entirely  completed  at  the  end  of 
four  weeks,  leaving  a  shortened  but  very  good-looking  and 
useful  toe,  with  plenty  of  soft  parts  covering  the  end  of  the 
bone.  On  examination,  the  tumor  was  found  to  consist  of  bone 
in  three  fourths  of  its  extent,  the  other  fourth  being  formed  of 
cartilage  which  covered  its  most  superficial  surface.  It  had  a 
decided  neck,  considerably  narrower  than  the  prominent  por- 
tion of  the  tumor.  The  adjoining  bone  seemed  sound.  The 
tumor  was  about  as  large  as  a  medium-sized  pea. 

This  gentleman  has  been  under  my  observation  up  to  the 
present  time.  Of  course,  there  has  been  no  return  of  the  dis- 
ease. His  toe  has  been  perfectly  well,  and  useful  in  every 
respect.  One  slight  drawback  to  his  entire  comfort,  however, 


232  TUMORS  OF  BONE. 

exists  in  the  foct  that  at  one  corner  of  the  wound  a  small, 
irregular  growth  of  nail  exists — the  evidence  that  some  portion 
of  the  matrix  escaped  the  knife.  This,  it  will  be  observed, 
occurred  also  in  Dr.  Buck's  case,  though  we  both  took  much 
pains  to  avoid  it.  The  accident  arises  from  the  fact  that  the 
corners  of  the  nail  are  sometimes  longer,  and  more  deeply  im- 
planted in  their  matrix,  than  the  central  portions,  and  that, 
therefore,  the  root  of  the  nail  has  a  straight  edge  terminating  in 
right  angles  with  the  sides.  Any  incision,  therefore,  which  is  to 
remove  the  matrix  entire,  must  not  curve  round  the  root  of 
the  nail,  but  must  extend  straight  across  the  dorsum  of  the 
finger  or  toe,  at  least  a  line  beyond  the  lateral  edges,  and  fully 
two  lines  back  of  the  apparent  root.  This  is  a  matter  of  much 
importance,  for  u  growth  of  nail  from  a  small  remaining  portion 
of  matrix  is  usually  a  deformed  and  irregular  growth,  and  gives 
as  much  trouble,  when  it  gets  long,  as  the  disease  for  which  the 
operation  was  performed.  In  Mr.  P.'s  case  he  was  so  much 
annoyed  by  the  growth,  while  the  cicatrix  was  still  recent  and 
tender,  that  I  proposed  to  destroy  the  remaining  matrix  with 
nitric  acid.  As,  however,  the  cicatrix  got  firm,  and  he  learned, 
too,  how  to  trim  the  nail-growth  with  a  sharp  knife,  it  became 
less  troublesome,  and  he  has  never  had  any  thing  done  for  its 
removal. 

Another  well-marked  case  of  this  exostosis  occurred  to  me 
in  the  person  of  Miss  E.,  aged  nineteen,  who  showed  me  in 
July,  1866,  a  hard  swelling  under  the  nail  of  the  right  big-toe. 
This  had  been  growing  gradually  for  several  months,  and  she 
could  attribute  it  to  no  evident  cause.  At  first  it  gave  her  no 
pain  or  inconvenience,  but  as  it  grew  more  prominent  it  gave 
rise  to  pain  in  walking,  particularly  with  a  new  or  tight  shoe. 
About  two  months  before  I  saw  it  she  had  showed  it  to  a  sur- 
geon, who  called  it  an  encysted  tumor,  and  performed  an  opera- 
tion for  its  relief.  This  operation  must  have  been  merely  the 
paring  off  of  the  superficial  portion  of  the  tumor,  for  it  was 
followed  by  no  benefit. 

The  nail  was  found  to  be  raised  by  a  firm,  solid  tumor,  evi- 
dently springing  from  the  bone.  The  superficial  portion  which 
projected  from  under  the  nail  was  covered  by  a  flaky,  horny 
epidermis  like  that  covering  an  ordinary  corn.  It  projected  to 


CARTILAGINOUS  TUMORS.  233 

one  side  of  the  median  line  of  the  nail,  and,  as  the  nail  had 
been  cut  away  on  one  side  to  relieve  the  pressure,  the  whole 
development  toward  the  surface  had  taken  place  quite  on  the 
side  of  the  nail.  Mr.  Paget  states  that  this  is  the  usual  fact 
with  regard  to  these  tumors,  and  that  they  rarely  grow  from 
exactly  the  middle  of  the  dorsum  of  the  phalanx.  Feeling  the 
tumor  deeply  and  firmly,  left  no  doubt  that  it  was  an  exostosis. 
Eemoval  being  the  only  remedy  I  had  to  pro- 
pose, the  operation  was  done  on  the  17th.  I 
proceeded  as  in  the  last  case,  being  careful  to 
remove  the  whole  matrix,  in  which,  this  time, 
I  succeeded.  The  stump  healed  soundly  and 
quickly,  leaving  a  very  comfortable  though  some- 
what shortened  toe. 

The  bone  removed  showed  the  usual  osseous 
base,  with  very  little  cartilaginous  tip.    This  was 
doubtless  due  to  the  operation  which  had  preceded  mine.     The 
whole  exostosis  was  about  the  size  of  a  large  pea,  and,  having  a 
somewhat  narrow  base,  and  an   expanded,  flattened  top,  pre- 
sented a  decided  mushroom  shape  (Fig.  56). 

The  seat  of  cartilaginous  tumors  is,  by  preference,  in  or 
upon  the  bones.  Many,  however,  are  found  in  other  tissues, 
as  the  mamma,  the  testicle,  and  some  of  the  internal  organs, 
where  they  seem  to  have  no  relation  whatever  to  any  bone. 
The  parotid  region  is  a  favorite  seat  of  these  growths ;  indeed, 
Mr.  Paget  remarks  that  the  greater  part  of  the  solid  tumors 
of  this  region  have  more  or  less  cartilage  in  their  composition. 
When  originating  from  bone,  the  tumor  may  grow  either  upon 
and  apparently  from  the  surface,  or  it  may  be  developed  within 
the.  cavities  of  the  bone,  which  in  its  growth  it  expands.  Mr. 
Stanley  thinks  that  this  difference  is  connected  with  the  size  of 
the  bone ;  thus  he  says  :  "  In  the  instances  of  its  occurrence  in 
any  of  the  larger  bones,  as  the  humerus,  femur,  or  tibia,  it  usu- 
ally grows  from  the  outside  of  the  bone,  rarely  within  it.  But 
in  the  instances  of  its  occurrence  in  any  of  the  smaller  bones, 
especially  of  the  hand  or  foot,  it  usually  originates  within  the 
bone."  The  explanation  of  this  peculiarity  he  does  not  give, 
and  probably,  in  the  present  state  of  our  knowledge,  it  cannot 
be  given.  As  a  pathological  law,  however,  it  is  not  without 


234 


TUMORS  OF  BONE. 


its  practical  importance,  and  would  certainly  have  a  bearing  on 
the  decision  of  the  question  of  amputating  the  limb  or  remov- 
ing the  tumor.  Mr.  Stanley  also  thinks  that  the  origin  of  these 
tumors  can  be  discriminated  by  the  character  of  the  external 
surface.  He  says  :  "  When  the  cartilaginous  tumor  originates 
within  a  metacarpal  or  digital  bone,  the  morbid  deposit  com- 
mencing in  the  cancellous  texture  is  in  some  cases  diifused 
through  it,  unaccompanied  by  pain  or  any  change  in  the  cover- 
ings of  the  bone  indicative  of  the  disease  within  it.  At  length, 
in  one  part,  and  it  may  be  on  one  side  only,  or  in  the  entire 
circumference  of  the  bone,  its  walls  expand  into  a  globular  tu- 
mor, consisting  of  a  thin,  osseous  shell,  enclosing  the  cartilagi- 
nous substance.  The  tumor  in  some  instances  remains  small, 
in  others  it  increases  to  the  size  of  an  orange.  But,  however 
large  the  tumor  may  be,  it  retains  the  osseous  shell,  which 
grows  with  the  increase  of  the  cartilage  within  it ;  and,  even 
when  of  largest  size,  the  tumor  is  unaccompanied  by  pain  or 
change  in  the  surrounding  tissues." 


FIG.  57.— (From  Cornil  and  Ranvier.) 


"  In  the  instances  of  the  cartilaginous  tumors  growing  from 
the  outside  of  a  bone,  the  exterior  of  the  tumor  is  usually  nod- 
uled,  its  cartilaginous  substance  is  disposed  in  lobes  united  by 


CARTILAGINOUS  TUMORS.  235 

fibrous  septa,  through  which  the  blood-vessels  ramify,  and  a 
fibrous  capsule  encloses  the  tumor." 

I  believe  that  this  may  be  an  important  diagnostic  mark 
between  the  two  forms  of  these  tumors,  and  as  such  be  ex- 
tremely useful ;  but  that  it  is  unvarying,  or  that  the  osseous 
shell  is  maintained,  when  the  tumors  grow  very  large,  is,  I 


FIG.  53.— (From  BUlroth.) 


think,  scarcely  ascertained  with  certainty.  On  this  point  of 
diagnosis  Mr.  Stanley  makes  the  further  remark  that,  when  a 
single  tumor  occurs  on  the  finger  or  toe,  it  is  usually  found  to 
grow  from  the  outside ;  but,  when  several  fingers  or  toes  are 


236 


TUMORS  OF  BONE. 


affected  with  these  growths,  they  usually  originate  within  the 
bone. 

A  favorite  seat  of  the  cartilaginous  tumor  is  the  hand,  and 
less  commonly  the  foot  (Figs.  57,  58,  59).  On  the  hand,  they 
often  affect  several  fingers,  the  tumors  not  all  appearing  at 
once,  but  following  one  another  at  longer  or  shorter  intervals. 
Here,  as  elsewhere,  the  growth  is  very  slow  and  painless,  and 
the  tumors  are  troublesome  mainly  from  their  bulk  interfering 
with  the  use  of  the  fingers.  They  usually  show  themselves 
first  in  early  childhood,  though  occasional  cases  are  noticed 
where  they  have  begun  in  advanced  life.  The  rate  of  growth, 

usually  slow,  is  sometimes  quite 
rapid,  and  the  rate  of  increase  is 
not  by  any  means  the  same  for 
every  tumor  of  the  same  hand ;  in- 
deed, it  is  most  often  seen  that  one 
or  more  tumors,  where  there  are 
many,  take  the  precedence  and  go 
on  rapidly  increasing  in  size,  and 
perhaps  may  pass  through  the  stages 
of  ulceration  and  destruction ;  while 
others  of  the  same  hand,  perhaps 
on  the  same  finger,  quietly  main- 
tain themselves  without  increase  or 
other  apparent  change.  In  these 

.  Hospital  Museum.)         tumorSj  ag    well    ag    m    t]loge    deyel. 

oped  in  the  larger  long  bones,  it  is  often  observed  that  the 
growth  has  commenced  both  within  and  without  the  bone, 
and  that  the  two  masses  of  cartilage  thus  growing  have  en- 
croached upon  the  bone  both  from  within  and  from  without, 
until  it  has  been  entirely  absorbed,  and  the  external  and  inter- 
nal tumors  have  coalesced  into  one,  the  continuity  of  the  bone 
being  entirely  interrupted  at  its  middle  portion.  In  this  con- 
dition a  slight  cause  will  produce  a  fracture,  and  the  destruc- 
tion of  the  bone  occasionally  advances  so  far  that  only  traces 
of  its  central  portion  can  be  discovered  in  the  mass,  while  the 
articular  ends  retain  their  integrity.  This  disappearance  of  the 
original  bone  is  sometimes  carried  still  further,  as  in  the  case 
of  single  tumor  of  hand  above  alluded  to.  This  case  was  in 


CARTILAGINOUS  TUMORS. 


237 


the  first  phalanx  of  the  middle  finger  of  a  patient  in  Bellevue 
Hospital — John  Shannon,  aged  sixty,  an  Irish  laborer,  who 
was  admitted  September  29, 1869.  The  turnor  had  been  grow- 
ing about  three  months,  and,  as  he  thought,  had  originated 
from  a  blow  against  a  mantel-piece  about  three  weeks  before 
the  appearance  of  the  tumor.  The  tumor  was  soft,  and  gave 
such  evidences  of  fluctuation  that  on  the  2d  of  October  an  ex- 
ploratory incision  was  made  about  three  inches  long.  A  cav- 
ity was  opened  containing  a  soft,  semi-fluid  mass,  which  easily 
broke  down  under  handling.  This  was  mingled  with  portions 
which  were  firmer  in  consistence,  and  in  particular  the  portion 
at  the  end  of  the  phalanx  was  distinct  in  its  appearance  and 
presented  a  sort  of  cauliflower  growth 
of  tolerable  firmness.  The  metacarpo- 
phalangeal  joint  was  encroached  on. 
The  finger  was  amputated  at  this  joint, 
and  the  wound  did  well.  The  tumor, 
examined  microscopically,  showed  all 
the  elements  of  enchondroma.  Pret- 
ty rapidly  the  tumor  grew  again,  now 
involving  the  metacarpal  bone,  and 
soon  reaching  a  size  greater  than  be- 
fore. On  the  12th  of  November  the 
hand  was  amputated.  The  wound  cica- 
trized without  accident,  and  the  man 
was  discharged  well,  November  29th. 

Dr.  Delafield  makes  the  following 
report  on  the  tumor :  "  The  carpal 
and  metacarpal  bones  are  almost  en- 
tirely replaced  by  a  tumor.  This  tu- 
mor is  enclosed  by  the  skin,  except  on 
the  back  of  the  hand,  near  the  base  of 
the  middle  finger,  which  had  been  re- 
moved. When  the  tumor  is  cut  into,  it  is  found  to  consist  of 
a  soft,  partly-gelatinous,  grayish,  semi-translucent  substance, 
traversed  in  different  directions  by  fibrous  bands.  Microscopi- 
cally examined,  it  consists  of  bands  of  fibrous  tissue,  mixed 
with  small,  round,  and  fusiform  cells  running  in  various  direc- 
tions. Enclosed  and  separated  by  these  bands  are  more  trans- 


238  TUMORS  OF  BONE. 

parent  portions  of  tissue.  These  portions  consist  of  a  basement- 
substance,  either  homogeneous  or  finely  granular,  or  faintly 
fibrillated.  Embedded  in  this  basement  substance,  in  some 
places  are  well-formed  cartilage-cells ;  in  other  places  the  cells 
are  of  more  irregular  shape,  are  mixed  with  small,  round,  and 
fusiform  cells,  and  are  in  such  numbers  as  almost  entirely  to 
obscure  the  basement-substance.  In  other  places  nothing  but 
small,  round  cells  can  be  seen,  and  here  the  basement-substance 
is  distinctly  fibrous,  and  is  arranged  in  small,  regular  alveoli. 
In  other  places  the  basement-substance  is  faintly  fibrillated, 
contains  only  a  few  oval  and  fusiform  cells,  and  resembles  mu- 
cous tissue." 

In  cases  where  the  growth  is  from  the  outside  only  of  the 
bone,  there  seems  to  be  less  tendency  to  its  destruction  (Fig. 
60). 


CHAPTER  II. 

OSSEOUS     TTTMOKS. 

.  TUMORS,  composed  entirely  of  bone,  are  found  almost  exclu- 
sively in  or  upon  the  bones,  though  some  rare  cases  are  reported 
of  perfect  tumors  of  this  sort  being  found  in  the  soft  parts  en- 
tirely disconnected  with  any  bone.  In  no  case  of  growth,  from 
any  part  of  the  body,  is  the  homology  of  the  new  formation 
more  absolute  than  it  is  in  many  of  these  tumors ;  they  pre- 
senting, in  most  cases,  not  only  an  exact  identity  in  intimate 
microscopical  structure  with  true  bone,  but  being  arranged  into 
compact  and  cancellous  tissue  with  as  much  regularity  and  per- 
fection as  are  the  original  bones  of  the  skeleton.  What  is  true 
of  the  structure  of  these  tumors  is  also  true  of  their  chemical 
composition,  which  by  numerous  observers  has  been  shown  to 
be  precisely  that  of  normal  bone,  and  most  of  the  variations 
which  the  chemical  composition  of  these  tumors  present  are 
not  greater  than  those  which  we  find  in  the  original  bones, 
under  the  varying  conditions  .of  age,  sex,  and  disease.  Of  the 
mode  of  development  of  these  perfect  osseous  tumors,  it  is 
perhaps  difficult  to  speak  positively,  because  it  frequently  hap- 


OSSEOUS  TUMORS.  239 

pens  that  no  trace  of  any  cartilaginous  or  fibrous  matrix  is 
found  in  any  part  of  the  tumor ;  but  the  analogy  is  so  clear 
and  so  strong,  with  the  development  of  ordinary  bone,  and  is 
borne  out  so  distinctly  by  those  tumors  when  we  do  trace  the 
ossific  process  in  its  progress,  that  there  can  hardly  be  any  rea- 
sonable doubt  that  they  are  formed  in  a  soft  matrix,  which  is 
sometimes  cartilaginous  and  sometimes  fibrous,  in  this  obeying, 
probably,  the  same  general  laws  as  those  which  determine  this 
difference  in  the /original  development  of  the  skeleton. 

Osseous  tumors  present  themselves  under  two  forms,  ac- 
cording as  the  cancellous  or  compact  tissue  prevails  in  their 
substance.  By  far  the  larger  number  present  a  well-formed 
cancellous  arrangement  in  their  interior,  and  an  equally  well- 
formed,  compact  shell  surrounding  them  on  the  outside.  In 
some,  however,  very  little  if  any  cancellous  substance  is  found 
to  exist,  the  whole  tumor  being  formed  of  solid,  very  dense, 
compact  substance,  giving  it  much  the  appearance  and  the 
weight  of  ivory.  Hence  we  have  the  distinction  into  the  ordi- 
nary cancellous  bony  tumor,  and  the  ivory-like  tumor,  two 
classes  which  differ  not  merely  in  the  facts  above  recited  as  to 
their  structure,  but  also  in  many  points  of  their  history,  as  well 
as  of  their  practical  relations.  These  two  classes,  therefore, 
may  advantageously  be  studied  separately ;  and  first  for  the  more 
common,  the  cancellous  class. 

The  cancellous  bony  tumors  occur  in  almost  every  possible 
situation,  sometimes  within  and  sometimes  upon  the  surface  of 
the  bones.  Their  history  is  usually  that  of  a  slow,  painless 
growth,  though  sometimes,  when  they  appear  to  have  been  pro- 
voked by  an  injury,  some  pain  and  soreness  accompany  their 
early  development.  When  they  grow  from  within  a  bone,  the 
external  shell  of  the  bone  is  usually  distended  by  the  growing 
tumor,  and  most  commonly  itself  forms  the  outer  shell  of  the 
tumor.  Indeed,  it  should  be  remarked  that,  in  these  cases,  as 
well  as  in  those  which  grow  from  the  surface,  the  line  of  dis- 
tinction between  the  tumor  and  the  original  bone  is  not  clear, 
and  perhaps  most  commonly  the  tissues  of  the  original  bone  are 
simply  continuous  with  the  tissues  of  the  new  growth,  so  that 
they  belong  to  the  class  which  Mr.  Paget  has  denominated  out- 
growths. So  strikingly  is  this  the  case,  that,  if  a  section  be  made 


240 


TUMORS  OF  BONE. 


of  some  of  these  which  grow  from  the  outside  of  the  long  bones, 
for  instance,  a  continuity  will  be  found,  not  only  of  the  outer 
fibres  of  compact  tissue,  but  also  of  the  cancellous  interior 
which  will  communicate  with,  and  be  continuous  with,  the  can- 
cellous interior  of  the  bone  upon  which  the  tumor  is  developed. 
These  tumors  are  usually  round  or  oval  in  shape,  and  present  a 
smooth,  even  surface ;  in  exceptional  cases  they  are  irregularly 
lobed.  Those  which  spring  up  from  the  surface  of  a  bone,  to 


FIG.  61.— (From  Billroth.) 

which  the  term  exostosis  is  more  properly  applied,  have  usually 
a  narrow  neck  by  which  they  are  attached  to  the  bone  from 
which  they  grow  (Fig.  61),  and  Mr.  Stanley  makes  the  state- 
ment that  in  the  increase  of  the  tumors  this  neck  does  not 
enlarge,  all  the  growth  taking  place  in  the  body  ot  the  tumor 


OSSEOUS  TUMORS.  241 

beyond  the  neck.  Mr.  Stanley  does  not  give  the  observations 
upon  which  this  idea  is  founded,  and  it  can,  therefore,  not  be 
accepted  as  proved ;  but,  even  if  it  be  a  fact  of  common  occur- 
rence, it  would  have  some  valuable  practical  bearings  on  the 
questions  of  the  time  for,  and  the  mode  of,  effecting  the  re- 
moval of  the  tumor.  Some  of  these  exostoses,  however,  have 
not  the  narrow  neck,  but  are  themselves  flat,  and  attached  by  a 
broad  surface  to  the  bone  from  which  they  grow.  And  here  it 
is  often  difficult  to  decide  as  to  the  real  nature  of  the  disease ; 
whether  it  is  a  proper  tumor,  or  whether  it  is  a  thickening  of 
the  original  bone-tissues,  by  inflammation  of  the  bone,  or  its 
periostea!  covering.  Happily,  the  diagnosis  is  not  of  practical 
importance,  for  the  question  of  removal  is  not  often  entertained, 
where  the  large  base  of  attachment  makes  the  removal  of  the 
whole  morbid  mass  uncertain  and  difficult. 

With  regard  to  the  seat  of  the  cancellous  exostoses,  scarcely 
any  bone  in  the  skeleton  is  entirely  exempt  from  them.  Per- 
haps the  most  frequent  seat  is  in  the  epiphysary  ends  of  the 
long  bones,  where  of  course  development  is  going  on  most  ac- 
tively, and  where,  in  young  persons,  they  may  be  considered  as 


FIG.  62.— (From  Heath.) 

due  to  a  morbid  excess  of  formative  activity.  Next  to  these 
points  in  frequency  are  the  jawbones,  both  upper  and  lower. 
Fig.  62,  taken  from  Heath,  is  a  good  example  of  the  cancellous 
exostosis  of  the  upper  jaw.  It  originated  in  the  left  superior 
maxilla,  projected  downward,  displacing  and  deforming  the 
lower  jaw,  and  largely  encroaching  on  the  mouth. 
16 


242 


TUMORS  OF  BONE. 


I  have  now  a  lady  tinder  my  care  who  has  an  exostosis,  of 
the  shape  and  size  of  a  small  cherry,  projecting  into  the  month, 
and  growing  from  about  the  middle  of  the  under  surface  of  the 
bony  palate.  It  has  been  growing  slowly  for  about  twelve 
years.  It  is  covered  with  healthy  mucous  membrane,  is  without 
pain,  and  gives  no  trouble  except  from  its  mechanical  presence. 
It  has  a  narrow  neck,  and  could  be  very  easily  removed. 

I  have  seen  recently,  with  my  friend  Dr.  E.  Krakowitzer, 
of  this  city,  a  young  lady  in  whom  a  tumor  is  slowly  growing 
on  the  right  parietal  bone,  and  has  now  reached  a  size  of  about 
an  inch  and  a  quarter  in  its  long  diameter.  It  appeared,  with- 
out cause,  about  ten  years  previous,  at  the  age  of  eleven.  It 
has  the  shape  of  a  section  of  the  blunt  end  of  an  egg,  and  rises 
about  half  an  inch  from  the  level  of  the  surrounding  bone. 
It  seems  to  be  immovably  fixed  to  the  bone,  though  occasionally 
we  thought  some  movement  could  be  developed  in  it  by  very 
strong  pressure  from  side  to  side,  as  if  to  slide  it  on  the  parietal 
bone.  A  needle  passed  down  to  its  surface  indicates  that  it  is 


FIG.  63.— (From  Billroth.) 

entirely  bone.  It  is  painless  and  free  from  any  tenderness,  and 
the  scalp  over  it  is  perfectly  healthy.  We  advised  that  for  the 
present  no  operation  should  be  thought  of.  Fig.  63  represents 
a  series  of  smaller  growths  of  this  kind  scattered  over  the  sur- 
face of  the  cranium. 


OSSEOUS   TUMORS.  243 

An  interesting  variety  of  exostosis  is  that  which  has  its  seat 
in  the  larger  tendons  just  at  their  point  of  attachment  into  the 
bone.  These  are  quite  common,  and  scarcely  a  museum  can  be 
found  which  has  not  one  or  more  of  these  growths.  They  seem 
to  be  developed  in  the  tendinous  tissue,  with  which  the  growth 
is  so  intimately  confounded  that  it  is  difficult  to  decide  whether 
the  bony  growth  has  taken  place  in  the  tendon-substance  as  a 
matrix,  or  whether  it  has  replaced  the  tendon  by  absorption  of 
its  fibres.  They  usually  have  a  base  of  attachment  to  the  bone 
no  larger  than  that  occupied  by  the  tendon,  and  sometimes  ex- 
tend a  considerable  distance  up  into  the  muscular  substance, 
the  direction  of  whose  fibres  the  increase  of  tumor  always  fol- 
lows (Fig.  64.)  According  to  my  observation,  these  exostoses 
are  always  found  in  strong,  well-developed  men,  in  whom  the 
muscles  and  tendons  are  large  and  vigorous,  and  the  bony  pro- 
cesses of  attachment  largely  developed ;  and,  if  this  be  so,  it  may 
be  fair  to  consider  these  also  as  a  result  of  an  excess  of  forma- 
tive power  irregularly  exercised,  rather  than  properly  a  disease. 
A  fine  specimen  of  this  exists  in  the  cabinet  of  the  New  York 
Hospital,  which  was  found  growing  from  the  femur  of  an  athletic 
negro,  "  in  whom  it  had  caused  no  symptoms,  and  about  the 
origin  of  which  nothing  was  known.  It  consists  of  a  mass  of 
bone,  six  inches  long,  springing  by  a  large  pyramidal  base  from 
the  shaft  below  the  trochanter  minor,  and  passing  downward  as 
a  slender,  tapering  process,  parallel  with  the  femur.  The  whole 
resembles  very  much  in  shape  a  snipe's  head  and  bill,  the  head 
representing  the  base,  and  the  bill  the  prolongation  down- 
ward." Fig.  65  shows  a  flat  exostosis  on  the  anterior  surface 
of  the  tibia. 

The  osseous  tumor  usually  gives  rise  to  no  symptoms  ex- 
cepting such  as  may  be  due  to  its  size,  or  to  its  pressure  upon 
neighboring  organs.  Thus  Mr.  Stanley  speaks  of  a  case  where 
a  man  had  an  exostosis  growing  from  the  posterior  surface  of 
the  clavicle,  in  whom  no  pain  was  experienced  while  the  arm 
was  at  rest,  "  but  directly  it  was  moved  he  suffered  acute  pain 
in  the  direction  of  the  axillary  plexus  of  nerves  and  its  branch- 
es ; "  and  also  of  another  "  in  whom  an  aneurism  was  supposed 
to  have  arisen  from  the  subclavian  artery ;  but,  upon  more  care- 
ful examination,  an  exostosis  was  discovered  growing  from  the 


244 


TUMORS   OF  BONE. 


first  rib,  pushing  the  artery  forward,  and  flattening  it.  Upon 
the  front  of  the  swelling  the  pulsation  was  strong,  and  extended 
over  a  large  space ;  but  at  its  sides  no  pulsation  could  be  felt. 
The  pulsation  of  the  artery  in  the  axilla  was  feeble.  In  the 


FIG.  64.— (Museum  of  College  of  Physicians 
and  Surgeons.) 


FIG.  65. — (Museum  of  College  of  Physicians 
and  Surgeons.) 


brnchial,  radial,  and  ulnar  arteries  no  pulsation  could  be  felt. 
Mr.  Stanley  also  refers  to  several  other  curious  localities  in 
which  exostoses  have  been  found.  Thus  he  alludes  to  one 
where  the  oesophagus  was  compressed  by  an  exostosis  growing 
from  the  body  of  one  of  the  vertebrae.  Another  is  recorded, 


OSSEOUS  TUMORS.  245 

where  a  conical  exostosis,  growing  from  the  posterior  part  of 
the  odontoid  process  of  the  second  cervical  vertebra,  caused  fatal 
compression  and  softening  of  the  spinal  cord.  He  mentions 
also  a  case  where  an  exostosis  grew  from  the  os  pubis  and  com- 
pressed the  neck  of  the  bladder,  so  that  a  catheter  could  not  be 
introduced ;  and  another  very  curious 
case  in  which  "  M.  Jules  Cloquet,  in 
examining  the  body  of  an  aged  female, 
found  the  symphysis  pubis  ossified,  and 
a  bony  growth  projecting  from  its  poste- 
rior surface  into  the  cavity  of  the  blad- 
der. The  pressure  of  the  tumor  had 
caused  the  absorption  of  the  coats  of 
the  bladder ;  hence,  on  opening  its  cav- 
ity, the  bony  tumor  was  seen  projecting 
into  it,  covered  only  by  a  thin  layer  of 
fibro-cellular  tissue,  which,  at  the  base  ^ 

FIG.  66.— (N.  T.  Hospital  Museum.) 

of  the  tumor,  was  continuous  with  the 

mucous  membrane  of  the  bladder."  Fig.  66  shows  a  very  com- 
mon form  of  exostosis  springing  from  the  sawed  end  of  a  femur 
after  amputation. 

The  exostoses  which  grow  from  the  inner  surface  of  the  dura 
mater,  and  from  the  internal  surface  of  the  cranium,  are  some- 
times the  cause  ot  various  cerebral  symptoms,  and  sometimes 
their  presence  has  not  been  suspected  from  any  sign  of  their 
existence  during  life.  Thus,  we  have  one  in  the  New  York 
Hospital  Museum,  which  is  developed  in  the  falx  cerebri,  and 
has  attained  a  size  and  thickness  sufficient  to  make  a  very  de- 
cided depression  in  the  cerebral  substance,  against  which  it  lay, 
and  yet  the  patient,  who  was  a  man  of  about  one  hundred  years 
of  age,  never  had  shown  any  sign  or  mark  of  cerebral  disturb- 
ance. On  the  other  hand,  Mr.  Stanley  alludes  to  the  case  of  a 
boy  who  was  "  admitted  into  St.  Thomas's  Hospital  on  account 
of  epileptic  fits,"  in  whom  "  a  spot  was  discovered  where  pressure 
gave  much  uneasiness.  Here  the  trephine  was  applied.  At  the 
instant  of  raising  the  circlet  of  bone,  he  had  a  sharp  epileptic 
fit ;  but  this  was  the  last.  From  the  inner  table  of  the  portion 
of  bone  removed,  a  spiculum  a  quarter  of  an  inch  long  pro- 
jected, pressing  upon  the  dura  mater."  Why  this  difference 


246 


TUMORS   OF  BONE. 


should  exist  between  tumors  which  seem  to  have  precisely  the 
same  physical  relations  to  the  cerebral  substance,  has  not,  as  far 
as  I  know,  been  particularly  investigated. 

A  feature  of  much  interest  in  these 
cancellous  exostoses  is  that,  sometimes, 
they  are  quite  numerous,  affecting  a 
number  of  bones  of  the  skeleton  (Fig. 
67).  Instances  of  this  kind  are  re- 
lated by  several  authors.  One  pre- 
sented itself  at  the  clinique  of  the 
College  of  Physicians  and  Surgeons, 
in  which  at  least  twenty  of  these  bony 
tumors  existed  at  various  points,  and 
usually  the  seat  of  the  tumor  corre- 
sponded on  the  two  sides  of  the  body. 
Thus  there  was  one  on  each  clavicle, 
one  on  the  upper  end  of  each  ulna, 
one  on  each  acromion  process  of  the 
scapula,  one  on  each  internal  malleo- 
lus,  besides  several  others  in  which 
the  correspondence  was  not  quite  so 


FIG.  67.— (From  Billroth.) 


FIG.  68.— (From  Heath.) 


perfect.  They  were  of  a  size  varying  from  that  of  a  pea  to 
that  of  a  walnut,  were  without  pain,  and  had  grown  slowly 
without  assignable  cause. 

An  interesting  variety  of  exostosis  is  that  which  we  occa- 
sionally find  developed  from  the  fangs  of  teeth,  and  which  con- 
sists entirely  of  hypertrophy  of  the  osseous  tissue  (cementum) 
of  the  tooth.  Fig.  68,  from  Heath,  gives  a  view  of  one  of  these 
exostoses  attached  to  the  side  of  a  molar  tooth.  It  was  as  large 
as  a  pigeon's  egg,  and  came  away  with  the  tooth  when  it  was 


OSSEOUS  TUMORS.  247 

extracted.  "  Under  the  microscope  the  specimen  was  seen  to 
contain  no  dentine,  but  to  consist  exclusively  of  osseous  tissue 
(cementum)." 

The  second  form  of  exostosis,  in  which  the  growth  consists 
principally,  and  sometimes  entirely,  of  compact  bone-substance, 
is  a  much  more  rare,  but  a  much  more  formidable  disease.  It 
usually  assumes  the  form  of  a  single  tumor,  and  its  favorite 
seat  is  in  the  bones  of  the  face  and  skull.  It  sometimes  pre- 
sents a  narrow  pedicle  or  base,  but  this  is  rare ;  the  most  com- 
mon mode  of  development  being  between  the  layers  composing 
the  bone,  as  in  the  diploe  of  the  supra-ciliary  ridge,  a  point 
which  these  tumors  very  commonly  aifect.  In  its  growth  the 
tumor  disparts  the  two  layers  of  bone,  which  are  extended  over 
it  at  first,  and  afterward  disappear,  or  are  confounded  with  the 
growth  which  gradually  pushes  its  encroachments  in  all  direc- 
tions, pressing  upon  the  cavities  of  the  orbit,  or  the  nose,  or  the 
mouth,  extruding  the  eye,  displacing  the  brain-substance,  and 
finally  producing  death  after  the  most  fearful  suffering,  and 
with  the  most  repulsive  features  of  deformity.  Cases  are  also 
sometimes  observed  where  no  distinct  tumor  can  be  traced  at 
any  time,  but  a  slow  enlargement  or  hypertrophy  of  the  affect- 
ed bones  takes  place,  which  gradually  develop  themselves  into  a 
hard,  irregular  mass,  which,  in  its  fully-formed  condition,  can- 
not well  be  distinguished  from  the  tumor  proper.  These  hyper- 
trophic  growths  are  principally  found  in  the  superior  maxillary 
bones,  but  the  disease  has  a  disposition  to  spread  to  adjacent 
bones,  pushing  its  encroachments  in  every  possible  direction. 
Mr.  Paget  gives  an  account  of  a  specimen  in  the  museum  of  the 
College  of  Surgeons,  in  which  "  two  large  masses  of  bone,  of 
almost  exactly  symmetrical  form  and  arrangement,  project  from 
the  upper  jaw  and  orbits,  and  have  partially  coalesced  in  the 
median  line.  They  are  rounded,  deeply -lobed,  and  nodular; 
nearly  as  hard  and  as  heavy  as  ivory ;  perforated  with  numerous 
apertures,  apparently  for  blood-vessels.  They  project  more 
than  three  inches  in  front  of  the  face,  and  an  inch  on  each  side 
beyond  the  malar  bones  ;  they  fill  both  orbits,  the  nasal  cavi- 
ties, and  probably  the  antra,  and  they  extend  backward  to  the 
pterygoid  plates.  Part  of  the  septum  of  the  nose,  and  the 
alveolar  border  of  the  jaw,  are  almost  the  only  remaining  indi- 


248 


TUMORS   OF  BONE. 


cation  of  a  face.  The  disease  appears  to  have  begun  in  the 
superior  maxillary  bones,  and  thence  to  have  spread  over  the 
bones  of  the  face ;  similar  disease,  in  a  less  degree,  existing  in 
the  bones  adjacent  to  the  chief  outgrowths.  The  patient,  who 
was  sixty  years  old,  believed  the  disease  had  been  eighteen 
years'  in  progress,  and  ascribed  it  to  repeated  blows  on  the  face. 

He  suffered  much  pain  in  the  lace, 
eyes,  and  head.  His  eyes  projected 
from  the  orbits  :  the  right,  after  sup- 
puration and  sloughing  of  the  cornea, 
shrivelled ;  the  left  was  accidentally 
burst  by  a  blow.  During  the  last 
two  years  of  his  life  he  occasionally 
showed  symptoms  of  insanity,  and  at 
last  he  died  with  apoplexy  of  the  cere- 
bral membranes."  (Fig  69.) 

In  all  these  cases,  however,  the 
chief  feature,  and  the  one  of  most 
practical  import,  is  the  gradual  in- 
crease of  the  osseous  mass,  until,  by 
its  sheer  intrusion  upon  the  surround- 
ing organs,  it  produces  so  much  injury  and  disturbance  as  finally, 
after  long  months  of  suffering,  to  destroy  the  patient.  And 
this  tendency  to  steady  increase  seems  to  be  characteristic  of 
this  form  of  bony  growth.  It  is  a  well-known  fact  that  the 
cancellous  exostosis  is  apt,  after  it  has  reached  a  certain  size,  to 
increase  very  slowly,  or  to  remain  stationary  during  indefinite 
periods,  perhaps  for  life.  These  ivory  exostoses,  on  the  con- 
trary, seem  to  have  an  inherent  tendency  to  increase,  which 
nothing  can  arrest,  save  the  death  of  the  sufferer. 

The  anatomical  character  of  these  ivory  exostoses  is  gener- 
ally that  of  pure  and  perfect,  but  very  hard,  bone-tissue.  The 
hardest  parts  of  these  tumors  present  sometimes  an  irregular 
distribution  of,  and  sometimes  an  absence  of,  the  usual  anatomi- 
cal elements  of  bone,  as  in  the  case  Mr.  Paget  alludes  to  in  the 
museum  of  the  University  of  Cambridge.  It  is  also  occasion- 
ally noticed  that  the  elements  of  bone  are  not  arranged  in  the 
usual  orderly  manner,  but  are  irregularly  distributed  about 
the  mass,  varying  somewhat  in  their  arrangement  at  various 


Fro.  69.— (From  Heath.) 


OSSEOUS  TUMORS.  249 

points  of  the  same  tumor.  Usually,  however,  the  bone-tissue 
is  perfect  in  every  respect,  and  cannot  by  the  microscope  be 
distinguished  from  bone  of  original  formation.  Many  of  these 
tumors  contain  nothing  but  the  hard,  ivory-like  bone-tissue,  but 
in  many  again  it  is  mingled  at  points  with  some  cancellous 
tissue,  and  some  tumors  are  recorded  which  present  a  thick 
outside  shell  of  hard  bone,  enclosing  cancellous  tissue  within, 
of  perfect  formation. 

Their  seat  is  most  commonly  the  bones  of  the  skull  and 
face,  and,  as  stated  above,  a  predilection  is  shown  for  the  orbital 
region,  in  or  about  which  a  large  proportion  of  these  growths 
originate.  Fig.  TO  gives  a  section  of  a  cranium  where  one  of 


FIG.  70.— (From  Paget.) 

these  tumors,  apparently  developed  in  the  supra-ciliary  region, 
has  grown  to  an  immense  size,  displacing  all  the  bones  of  the 
face,  and  projecting  backward  into  the  cranial  cavity.  The 
specimen  is  in  the  museum  of  the  University  of  Cambridge, 
and  Mr.  Paget,  from  whose  work  the  plate  is  copied,  says  of  it : 
"  It  is  the  largest  and  best  specimen  of  the  kind  I  have  ever 
seen,  and  its  osseous  structure  is  distinct ;  only,  as  Prof.  Clark 
has  informed  me,  it  is  irregular ;  in  the  hardest  parts  there  are 
neither  Haversian  canals  nor  lacunae ;  in  the  less  hard  parts  the 
canals  are  very  large,  and  the  lacunae  are  not  arranged  in  circles 
about  them;  and  everywhere  the  lacunas  are  of  irregular  or 


250  TUMORS  OF  BONE. 

distorted  forms."  They  are  occasionally  found  in  other  parts 
of  the  skull  and  face,  and  sometimes,  though  rarely,  there  is 
more  than  one,  as  in  the  specimen  in  the  Musee  Dupuytren, 
alluded  to  by  Follin,  and  of  which  he  gives  a  drawing.  Here 
two  distinct  osseous  masses  existed,  one  on  the  anterior  and 
one  on  the  posterior  part  of  the  vault  of  the  cranium,  each 
projecting  about  equally  from  the  outer  and  inner  surfaces 
of  the  bone,  the  inner  projection  largely  encroaching  upon 
the  cerebral  cavity.  These  tumors  are  occasionally  devel- 
oped in  the  lower  jaw,  and  very  rarely  in  other  bones.  It 
is  curious  to  observe  that,  sometimes,  the  hypertrophic  out- 
growth that  we  find  as  the  result  of  periosteal  inflammation 
puts  on  this  ivory-like  character,  and  sometimes  vies  in  solidity 
with  the  hardest  of  the  tumors.  Thus,  in  a  specimen  in  the 
Kew  York  Hospital  Museum,  which  presents  an  enlargement 
of  the  anterior  half  of  the  tibia,  evidently  from  periosteal  irri- 
tation, the  new  material  which  has  been  deposited,  to  the  thick- 
ness of  more  than  half  an  inch,  is  shown  by  the  section  to  be 
of  the  hardest  and  most  solid  kind  of  bone,  in  which  no  can- 
celli  and  no  vascular  canals  can  be  seen,  by  the  naked  eye.  The 
immense  weight  of  the  bone  confirms  its  solidity.  This  speci- 
men seems  to  mark  the  dividing  line  between  the  ivory  tumors 
proper  and  those  enlargements,  above  alluded  to,  which  are  so 
general,  and  involve  in  their  progress  so  large  a  part  of  the 
affected  bone  that  they  more  naturally  suggest  the  idea  of  an 
hypertrophy  than  of  a  simple  tumor. 

Of  the  cases  in  which  the  tumor  character  is  the  most 
marked,  a  number  of  examples  are  on  record.  One  classical 
case  is  given  by  Mr.  Heath,  which  was  under  the  care  of  Sir 
"William  Fergusson,  in  King's  College  Hospital.  The  patient 
was  twenty-one  years  of  age,  and  the  tumor  had  appeared 
twelve  years  before.  It  was  the  size  of  an  apple,  and  occupied 
the  situation  of  the  orbit  from  which  it  projected,  carrying  out 
with  it  the  eyeball.  The  tumor,  after  removal,  was  found  to 
consist,  "in  all  its  anterior  part,  of  nodulated  bone  as  hard  as 
ivory,  and  posteriorly  of  very  dense  ordinary  bone,  mixed  with 
a  small  amount  of  cartilage.  The  tumor  sprang  apparently,  as 
in  the  former  case,  from  the  upper  parts  of  the  maxilla,  and  had 
invaded  the  antrum,  orbit,  and  nostril." 


OSSEOUS  TUMORS.  251 

Mr.  Heath,  also  alludes  to  Micliou's  case,  in  which  the  tumor 
occupied  the  cavity  of  the  antrum,  springing  from  its  upper  or 
orbital  wall,  and  distending  it  in  all  directions.  "It  weighed 
eighteen  hundred  grains,  and  was  deeply  lobulated,  particularly 
on  its  posterior  aspect.  A  section  showed  concentric  markings 
upon  a  surface  of  ivory,  and  microscopic  examination  demon- 
strated the  lacunae  and  canaliculi  of  true  bone." 

Dr.  Duka's  case  ("Pathological  Society  Reports,"  vol.  xvii.) 
was  still  more  remarkable,  "  and  occurred  in  a  female  native  of 
Bengal,  aged  twenty-six,  on  the  right  side  of  the  face,  which 
was  not  much  deformed.  There  was  a  discharge  from  the  right 
nostril,  which  was  obstructed,  and  on  examination  a  hard  tumor 
was  found  within  it,  which  was  movable,  but  could  not  be  ex- 
tracted, and  which  had  existed  six  years."  It  was  removed 
with  much  difficulty,  and  the  specimen  is  in  St.  George's 
Hospital  Museum.  "It  has  an  oblong  shape,  and  is  not  unlike 
a  middle-sized  potato,  with  depressions  and  elevations  passing 
irregularly  over  it.  The  upper  part,  which  is  believed  to  have 
been  in  contact  with  the  cribriform  plate  of  the  ethmoid  bone, 
exhibits  corresponding  delicate  depressions,  with  other  deeper 
sulci  in  front,  behind,  and  on  the  side,  probably  for  the  passage 
of  blood-vessels.  ...  The  wrhole  bony  mass  weighs  one  thou- 
sand and  sixty  grains ;  its  long  diameter  is  nearly  three  inches, 
the  short  one  an  inch  and  two  lines,  and  the  longest  circum- 
ference seven  inches.  There  are  no  distinct  Haversian  systems, 
but  abundance  of  lacunae  arranged  around  vascular  canals.  In 
some  parts  of  the  tumor  the  characters  are  very  much  like  those 
of  simple  ossified  cartilage." 

Fig.  71,  from  Heath,  is  a  good  example  of  the  ivory  exos- 
tosis  growing  from  the  angle  of  the  lower  jaw.  The  tumor 
projects  both  downward  and  on  each  side  of  the  jaw,  and 
measures  nearly  three  inches  in  its  longest  diameter.  It  is 
composed  throughout  of  bone,  uniform  in  texture,  and  as  hard 
and  heavy  as  ivory. 

Two  accidents  are  apt  to  happen  to  these  tumors,  which 
present  some  points  of  pathological  interest.  I  allude  to  necro- 
sis and  fracture.  In  several  instances  it  has  been  noticed  that 
inflammation  has  attacked  these  growths,  and  that  after  its 
subsidence  abscess  has  been  formed,  communicating  with  and 


252  TUMORS  OF   BONE. 

exposing  the  stirface  of  the  bone,  which  has  gradually  fallen 
into  the  condition  of  a  sequestrum,  which  sequestrum  has  finally 
separated  from  the  surrounding  bone,  and  become  detached, 
leaving  a  granulating  cavity,  which  in  several  recorded  in- 
stances has  perfectly  healed.  In  Mr.  Hilton's  case,  the  process 


Fio.  71.— (From  Heath.) 

of  separation  was  going  on  for  six  years  before  it  was  finally 
completed.  Acting  upon  this  hint,  Sir  Astley  Cooper  made 
the  suggestion  that  an  incision  should  be  made  down  upon 
such  a  tumor,  exposing  its  surface,  and  detaching  it  from  the 
surrounding  soft  parts,  in  the  hope  that,  by  such  exposure,  ne- 
crosis would  take  place,  and  a  spontaneous  separation  occur. 
"Whether  any  such  expectation  has  ever  been  realized,  I  am  not 
informed. 

"With  regard  to  fracture,  the  only  instance  that  I  know  of  in 
which  the  ivory  exostosis  has  been  separated  in  this  way  is  Dr. 
Duka's  case,  before  mentioned,  in  which  the  tumor  growing  in 
the  antrum  had  separated  from  its  bony  attachments,  and  was 
lying  loose  in  the  cavity.  The  cancellous  exostoses,  however, 
and  particularly  where  they  have  acquired  a  narrow  base  of  at- 
tachment, are  not  unfrequently  broken  oif.  Several  examples 
are  recorded  of  this  accident,  and  the  suggestion  has  been  made 
to  break  them  off,  with  a  view  to  arrest  their  growth,  as,  in  the 


OSSEOUS  TUMORS.  253 

instances  known,  no  growth  has   occurred  after  the  base  of 
attachment  has  been  broken  through. 

In  all  these  different  forms  of  tumors  situated  on  bones,  the 
question  of  operative  interference  is  liable  to  present  itself.  It 
may  be  asserted  as  a  general  fact  that,  in  any  case  in  which  the 
tumor  can  be  completely  removed,  the  operation  will  be  likely 
to  be  successful.  It  must  be  remembered,  however,  that  in  only 
a  small  proportion  of  bone-tumors  is  the  base  so  distinct  and  so 
small  that  the  surgeon's  saw  or  chisel  can  reach  the  whole  of 
its  attachment  with  ease  and  certainty ;  and  that,  therefore,  in 
these  cases  the  removal  is  apt  to  be  imperfect  and  partial.  I  do 
not  mean  to  say  that,  in  all  cases  in  which  the  whole  diseased 
tissue  is  not  removed,  a  recurrence  will  take  place,  but  that  in- 
complete removal  leaves  a  disposition  to  recurrence  I  suppose 
no  surgeon  will  deny,  and  that,  therefore,  the  possibility  of 
complete  removal  becomes  an  important  element  in  deciding 
upon  the  propriety  of  an  operation.  In  many  exostoses  which 
have  a  narrow  and  accessible  neck,  the  mere  removal  of  the 
mass  by  incision  through  this  neck  is  sufficient,  for,  as  above 
stated,  the  stump  thus  left  shows  very  little  inclination  to  grow; 
but,  in  many  others,  when  the  base  of  attachment  is  large,  and 
the  tumor  situated  deeply,  the  operation  of  removal  is  among 
the  most  difficult,  tedious,  and  troublesome,  in  surgery.  These 
difficulties  were  experienced  in  the  fullest  degree  by  my  col- 
league, Dr.  John  Watson,  in  a  case  of  exostosis  of  the  middle 
of  the  femur,  which  he  was  engaged  in  removing.  The  depth 
of  the  wound,  though  a  liberal  one,  and  the  unyielding  nature 
of  the  tendinous  and  aponeurotic  tissues  near  the  bone,  pre- 
vented very  seriously  the  oblique  application  of  the  chisels  and 
forceps,  which  was  necessary  to  get  at  the  base,  and  which 
would  have  been  so  easy,  could  the  soft  parts  have  been  re- 
moved. After  a  long  and  laborious  operation,  conducted  with 
much  patience,  in  his  usual  thorough  manner,  he  succeeded  in 
removing  the  whole  growth,  and  the  wound  was  brought 
together.  Severe,  deep-seated  inflammation  followed  rapidly, 
and  spread  up  and  down  the  thigh,  terminating  in  unhealthy 
suppuration,  and  bringing  the  patient  so  rapidly  down  that  he 
sank  and  died  about  a  week  from  the  operation.  It  seemed  as 
if  the  violence  done  to  the  tissues  about  the  tumor,  by  the  ne- 


254  TUMORS  OF  BONE. 

cessary  manipulation,  had  provoked  an  inflammation  which  the 
injured  parts  were  not  able  to  resist,  and  hence  the  fatal  exten- 
sion of  its  ravages. 

Nevertheless,  if  the  tumor  be  growing  rapidly ;  if  it  involve 
parts  where  its  pressure  may  become  dangerous,  or  painful,  or 
even  inconvenient ;  if  it  be  situated  where  it  is  a  deformity ;  in 
short,  if  there  be  any  good  reason  for  desiring  its  removal,  the 
operation  may  be  undertaken  with  a  good  prospect  of  perfect 
success ;  if,  as  above  stated,  the  mechanical  conditions  of  the 
tumor  and  its  surroundings  be  such  as  will  permit  of  its  easy 
and  complete  removal.  As  to  the  mode  of  accomplishing  the 
removal,  so  much  will  depend  on  the  nature  and  seat  of  the 
growth  that  specific  rules  can  hardly  be  laid  down.  The  first 
step  will  be  to  expose  the  tumor  by  an  incision,  which  should 
be  a  liberal  one,  and  in  deep  tumors,  in  fleshy  parts,  Mr.  Stan- 
ley gives  direction  to  cut  the  muscular  fibres  transversely,  both 
because  it  exposes  the  seat  of  disease  more  thoroughly,  by  the 
retraction  of  the  fibres,  and  because  it  leaves  the  wound  better 
open  for  the  discharge  of  matter  during  the  healing  process. 
The  bone  is  to  be  attacked  by  saws,  chisels,  or  bone-forceps,  ac- 
cording to  circumstances,  and  the  whole  diseased  tissue,  with  a 
liberal  portion  of  the  surrounding  sound  bone,  should  be  re- 
moved, if  it  can  with  safety  be  done.  In  my  own  hands,  the 
chisel  (and  particularly  a  moderate-sized  gouge  with  rounded 
cutting  edge)  is  the  most  effective  and  most  generally  useful 
instrument  I  employ.  It  is,  however,  in  the  ivory  exostosis, 
about  the  face  and  head,  that  the  most  formidable  operative 
difficulties  present  themselves.  In  the  following  case  the 
manipulations  are  not  stated  to  have  been  difficult : 

Dr.  Alexander  B.  Mott,  of  this  city,  was  the  operator,  and 
the  patient,  a  Scotchman,  thirty-three  years  of  age,  of  good 
constitution  and  health,  had  noticed  for  seven  years  an  enlarge- 
ment about  the  inner  canthus  of  the  left  eye.  It  commenced 
without  obvious  cause,  and  gradually  became  the  seat  of  great 
pain  as  it  grew  larger.  Its  growth,  at  first,  was  toward  the 
nasal  cavities,  and  afterward  toward  the  orbit,  projecting  also 
from  the  surface  of  the  cheek  and  side  of  the  nose.  Lately  an 
abscess  had  formed  and  discharged  near  the  inner  canthus.  On 
passing  a  probe  through  the  opening  of  this  abscess,  bare  bone 


OSSEOUS  TUMORS.  255 

could  be  felt.  The  deformity  was  still  further  increased  by  the 
left  eye  being  pressed  by  the  tumor  very  much  from  its  proper 
position,  a  consequence  of  which  pressure  was  a  very  great  im- 
pairment of  vision,  amounting  finally  almost  to  a  total  loss. 
Dr.  Mott  exposed  the  surface  of  the  tumor  by  making  four 
flaps,  and  dissecting  them  up  from  their  attachments.  "  This 
being  done,  I  found  the  bony  tumor  was  firmly  impacted  in  the 
orbit  and  nasal  cavity.  I  consequently  separated  the  nasal  bone 
of  the  left  side  from  its  fellow  of  the  opposite  side  by  means  of 
a  strong  pair  of  Liston's  bone-forceps,  and,  with  a  fine,  straight, 
flexible  saw,  detached  it  from  its  frontal  attachment.  By  a 
little  manipulation  I  was  thus  enabled  to  remove  the  portion 
represented  in  Fig.  72,  and,  on  accomplishing  this,  I  next,  by 


FIG.  72.— (From  Dr.  A.  B.  Mott's  Collection.) 

means  of  a  delicate  chisel  and  hammer,  gradually  detached  the 
other  bony  mass  from  the  orbital  plate  of  the  frontal  bone,  and 
also  from  the  orbital  plate  of  the  superior  maxillary.  The  os 
unguis  was  so  thoroughly  incorporated  with  the  tumor  that  I 
was  obliged  to  remove  it  along  with  the  mass ;  and  the  whole 
being  now  somewhat  movable,  I  made  slight  traction  by  means 
of  a  pair  of  strong  forceps.  A  few  more  cuts  of  the  chisel  en- 
abled me  to  withdraw  it."  The  tumor  was  found  to  be  of  dense 
osseous  structure,  and  is  represented  in  the  plate  of  natural  size. 
Its  weight  was  three  ounces  and  one  drachm.  The  patient 


256  TUMORS  OF  BONE. 

made  a  very  good  recovery,  and  has  since  remained  entirely 
free  from  any  symptom  of  return  of  the  affection,  a  period  of 
about  thirteen  years. 

Sir  William  Fergusson,  M.  Michou,  Dr.  Duka,  M.  Demar- 
quay,  and  others,  have  published  full  accounts  of  their  opera- 
tions on  these  tumors,  and,  though  the  number  of  operations  is 
too  few  to  be  of  any  statistical  value,  the  general  result  seems 
to  be,  for  so  serious  an  operation,  quite  encouraging.  Sir  Wil- 
liam Fergusson's  case  died,  but  the  three  other  surgeons  named 
above  were  successful  in  curing  their  patients. 


CHAPTER  III. 

FIBKOUS     TTJMOKS. 

THE  pure  fibrous  tumor  is  not  rare  in  the  bones ;  most 
commonly  connected  with  the  periosteum,  of  which,  as  in  some 
forms  of  epulis,  it  seems  to  be  an  outgrowth ;  but  sometimes 
found — as  in  the  upper  and  lower  jaws — developed  in  the  sub- 
stance of  the  bone  itself.  These  tumors  are  commonly  typical 
specimens  of  their  class,  being  composed  entirely  of  the  white 
fibrous  tissue,  containing  scarcely  any  other  element,  and  with 
no  trace  of  stroma  or  basement -substance,  in  which  the  fibres  are 
embedded.  Some  differences  in  structure,  however,  are  found. 
Thus,  some  are  harder  and  drier,  others  softer  and  more  juicy ; 
some  show  the  fibres  cleanly  defined  and  distinct,  others  show 
merely  a  general  fibrous  character,  in  which  it  is  not  always 
quite  easy  to  distinguish,  and  quite  impossible  to  isolate,  sepa- 
rate fibres.  Some  show  a  distinct  basement-substance,  hard, 
firm,  and  white,  almost  like  cartilage,  in  which  fibres  are  vari- 
ously interlaced,  sometimes  in  comparatively  small  numbers ; 
others,  again,  particularly  the  harder  specimens,  are  so  com- 
pact and  condensed  in  their  structure  that  nothing  but  careful 
microscopical  examination  will  reveal  the  fact  that  they  are 
composed  of  nothing  but  fibres.  Elastic  fibres  are  sometimes 
scattered  through  the  tumor  in  considerable  abundance,  though 
in  a  large  proportion  of  cases  they  are  entirely  absent.  Nuclei 


FIBROUS   TUMORS.  257 

are  also  found  in  young  fibrous  tumors,  and  in  those  which  are 
growing  rapidly,  while  in  the  older  and  more  stationary  exam- 
ples they  may  be  entirely  absent.  Again,  cartilage  and  bone  are 
not  unfrequently  met  with  in  apparently  accidental  association 
with  the  fibrous  tissue,  though  true  bone  is  not  often  found  in 
large  amount  in  this  form  of  tumor.  It  is  true  that  there  is  a 
change  in  many  of  them,  wherein,  by  a  process  of  slow  degen- 
eration, the  chemical  elements  of  bone  are  so  largely  infiltrated 
through  the  tumor  that  it  finally  becomes  a  hard,  solid  mass,  as 
heavy  and  as  solid  as  bone,  which  to  the  naked  eye  it  sometimes 
resembles ;  but  this  is  calcification,  not  ossification,  and  the  ele- 
ments are  seen,  under  the  microscope,  not  to  have  assumed 
any  of  the  characters  of  true  bone.  Cysts  also  are  developed 
in  fibrous  tumors,  sometimes  many  being  scattered  through 
their  substance,  while  it  sometimes  happens  that  one  large  cyst 
so  displaces  and  replaces  the  original  structure  that  its  char- 
acter as  a  primary  fibrous  growth  is  difficult  or  impossible  to 
recognize. 

The  external  features  of  these  tumors  are  somewhat  con- 
stant. They  have  a  distinct  and  usually  smooth  boundary-line, 
which  separates  them  from  the  surrounding  tissues,  from  which 
they  can,  by  enucleation,  be  readily  removed.  This  is  true  of 
those  portions  whereby  they  come  in  contact  with  parts  other 
than  the  bone  or  periosteum,  from  which  they  spring.  In  their 
mode  of  connection  with  these  latter,  considerable  differences 
present  themselves.  Thus,  from  the  periosteum  they  often 
have  the  character  of  outgrowths,  in  which  no  boundary-line 
exists  between  the  tumor  and  the  tissue  from  which  it  is  devel- 
oped, and  in  some  cases  not  even  the  microscope  can  discrimi- 
nate between  the  new  growth  and  its  parent-tissue.  In  other 
cases  a  line  of  separation  can  be  traced  through  the  whole  con- 
tour of  the  new  growth,  and  even  in  some  instances  the  tumor 
has  no  contact  with  the  fibrous  structures  near  which  it  grows, 
but  is  at  every  point  separated  from  them  by  a  loose  areolar  in- 
terspace. This  is  occasionally  noticed  in  fibrous  tumors  grow- 
ing about  the  metatarsus  and  metacarpus.  The  external  sur- 
face of  these  tumors  is  usually  rounded  and  smooth,  sometimes 
lobed,  rarely  bosselated  or  botryoidal.  Their  consistence  is 
very  hard ;  their  specific  gravity,  as  a  class,  greater  than  any 
17 


258  TUMORS  OF  BONE. 

other  but  the  osseous.  Their  vascularity  is  generally  slight, 
though  some  of  the  softer  forms  receive  a  large  number  of 
vessels. 

They  are,  in  the  bones,  usually  single,  their  growth  is  very 
slow  and  painless,  and  they  sometimes  attain  a  very  great  size. 
With  regard  to  their  constitutional  character  they  are,  by  gen- 
eral consent,  considered  to  be  uniformly  benign.  Their  ten- 
dency, however,  to  local  reproduction,  particularly  if  imper- 
fectly removed,  is  well  marked,  and  in  operating  must  not  be 
lost  sight  of.  The  malignant  history  of  some  "  fibroid  tumors  " 
must  not  lead  us  to  the  unjust  imputation  of  evil  character  to 
any  of  those  which,  under  the  microscope  as  well  as  to  the 
naked  eye,  deserve  the  name  of  "  fibrous  tumors."  In  short, 
it  may  be  stated,  as  the  expression  of  a  general  law,  to  which 
there  are  very  few  exceptions,  that  the  benignity  of  these  tu- 
mors is  in  direct  proportion  to  the  perfection  which  the  fibrous 
element  has  attained  —  those  which  represent  perfect  fibrous 
tissue  being  absolutely  benign,  and  those  which  present  it 
in  a  less  perfect  state,  and  particularly  in  its  embryonal  form, 
are  always  to  be  looked  upon  with  a  certain  amount  of  sus- 
picion. 

The  seat  of  these  tumors  is  sometimes  on  the  surface  of  the 
bone,  and  then  they  may  fairly  be  supposed  to  originate  in  the 
periosteum,  with  which  they  are  commonly  continuous,  or  it 
is  in  the  central  parts  that  they  are  developed,  and  then  they 
usually  distend,  in  their  growth,  the  compact  outer  shell  of  the 
bone,  which  often,  even  in  tumors  of  the  largest  size,  forms 
a  thin,  uniform  covering,  sometimes  not  thicker  than  an  egg- 
shell, which  gives  them,  on  a  slight  touch,  the  feel  of  a  bony 
tumor,  but  which,  by  firmer  pressure,  yields,  and  sometimes 
crackles  under  the  finger  like  a  broken  egg-shell.  They  have 
been  found  in  or  upon  most  of  the  larger  bones,  usually  near 
their  cancellous  rather  then  the  compact  portions.  They  have 
been  noticed  of  very  large  size  in  the  femur,  humerus,  and 
scapula.  We  have  one  very  marked  example  of  one  of  these 
tumors  in  the  museum  of  the  New  York  Hospital,  devel- 
oped in  the  lower  part  of  the  femur,  which  had  been  six  years 
growing,  and  which,  at  the  time  of  amputation,  measured  thir- 
ty-seven inches  in  circumference.  Mr.  Stanley  speaks  of  one, 


FIBROUS  TUMORS.  259 

in  the  museum  of  St.  Bartholomew's,  which  grew  from  the  hu- 
merus,  and  which  measured  three  feet  in  circumference.  Oth- 
ers of  very  large  size  have  been  recorded  in  the  scapula.  It  is, 
however,  in  the  maxillae,  both  upper  and  lower,  that  the  fibrous 
tumors  are  most  commonly  found,  and  have  been  most  carefully 
studied.  For  many  reasons  the  tumors  of  the  jaws  can  be  most 
conveniently  considered  together,  and  I  therefore  postpone  any 
more  particular  account  of  fibrous  tumors  of  the  bone,  till  we 
come  to  the  chapter  devoted  to  the  study  of  the  various  tumors 
which  affect  the  jaws. 

SPINDLE-CELLED   FIBROIDS. 

A  considerable  number  of  bone-tumors  present  themselves, 
of  which  the  histological  character  is  given,  by  the  presence  of 
spindle-shaped  or  oat-shaped  cells,  which  compose  the  mass  of 
the  tumor,  often  to  the  exclusion  of  any  other  element.  From 
the  distinctness  of  their  anatomical  characters,  and  the  facility 
with  which  these  characters  may  be  recognized,  these  tumors 
have  long  been  known,  and  have  been  described  by  all  modern 
writers.  But,  some  controversy  having  arisen  with  regard  to 
their  histogenesis,  different  names  have  been  given  to  them  by 
different  observers,  in  accordance  with  their  different  views,  as 
to  the  signification  of  the  microscopical  elements  of  which  they 
are  composed. 

Lebert  first  drew  attention  to  them  as  a  class  worthy  of 
separate  consideration,  and,  as  he  adopted  very  confidently  the 
idea  that  the  elongated  cells,  of  which  they  were  composed, 
were  nothing  more  than  fibre-cells  arrested  in  a  certain  stage 
of  development,  he  named  them,  very  appropriately,  if  his  view 
were  correct,  fibro-plastic  tumors.  Billroth,  Virchow,  and  oth- 
ers of  the  modern  German  school,  have  protested  against  this 
view,  and  have  shown  that  in  the  formation  of  fibrous  tissue  in 
the  embryo  there  is  no  stage  or  condition  which  presents  the 
spindle-shaped  cells,  and  that,  therefore,  Lebert's  view  being 
incorrect,  the  name  he  u'ses  is  inappropriate.  Billroth  insists 
that,  if  these  peculiar  cells  represent  a  stage  of  incomplete  de- 
velopment of  any  tissue,  it  is  the  muscular  fibre,  and  not  the 
fibrous  tissue,  to  which  they  belong,  and  that  therefore  they 
ought  to  be  included  under  the  myomata,  or  tumors  composed 


260  TUMORS  OF  BONE. 

of  muscular  fibres,  rather  than  under  the  fibromata,  with  which 
they  have  no  proved  relation.  Virchow  pronounces  the  spin- 
dle-shaped cells,  which  are  often  found  in  uterine  fibroid,  as 
imperfectly-developed  muscle-cells,  and  gives  these  tumors  the 
name  of  " myoma  laeve  cettulare"  In  comparing  the  views  of 
the  best  microscopists,  it  seems  doubtful  whether  white  fibrous 
tissue  is  ever  developed  from  cells  at  all,  and  even  Yirchow, 
the  great  advocate  of  the  doctrine  "  omnia  ex  cellula"  acknowl- 
edges that  in  the  formation  of  fibrous  tissue  it  is  the  intercel- 
lular substance  and  not  the  cells  which  are  concerned  in  its 
development.  The  yellow  elastic  tissue,  it  is  true,  seems  to  be 
developed  from  cells,  but  this  element  is  comparatively  uncom- 
mon in  fibrous  tumors,  and  has,  therefore,  but  little  signification 
as  far  as  histogenesis  is  concerned.  It  is  not  without  reason, 
therefore,  that  pathologists  have  rejected  Lebert's  term,  "  fibro- 
plastic,"  as  conveying  an  incorrect  idea ;  but  still  it  is  necessaiy 
to  remember  that,  though  his  theory  of  formation  is  unsound, 
and  his  nomenclature  therefore  faulty,  his  observations  are  nev- 
ertheless clear  and  admirable,  and  that  from  his  labors,  and 
from  the  contributions  made  by  numerous  other  observers,  we 
have  a  fair  ground  for  including  in  one  class  all  those  tumors 
that  are  mainly  composed  of  these  peculiar  and  easily-recog- 
nized cells.  This  class  would  include  all  those  cases  so  well 
described  by  Lebert,  as  well  as  those  described  by  Mr.  Paget 
under  the  title  of  recurring  fibroid  tumors,  those  called  by 
Billroth  spindle-shaped  sarcomata,  and  those  which  Virchow 
denominates  sarcomata  with  fusiform  cells.  It  will  perhaps  be 
convenient  for  us  to  denominate  them  the  spindle-celled  fibroids, 
as  an  appellation  which  embraces  the  facts  in  the  case,  without 
the  suggestion  of  any  theory. 

These  tumors,  as  their  name  imports,  have  a  nearer  resem- 
blance, in  their  naked-eye  characteristics,  to  the  fibrous  than  to 
any  other  tumors.  Indeed,  the  firmer  specimens  cannot  in  any 
way  be  distinguished  from  the  fibrous  growth,  except  by  the 
aid  of  the  microscope.  They  are  usually  tolerably  firm,  of  a 
whitish  homogeneous  section,  from  which  but  little  juice  can 
be  scraped,  not  very  liberally  supplied  with  blood-vessels,  and 
usually  uniform  in  their  appearance  throughout  their  whole 
substance.  When  they  recur  after  removal,  their  appearance 


FIBROUS  TUMORS.  261 

is  often  much  changed  to  the  naked  eye  ;  they  are  softer,  like 
the  flesh  of  fish ;  they  are  more  juicy  and  more  vascular,  in 
each  recurrence  departing  more  widely  from  the  fibrous  appear- 
ance, but  showing  under  the  microscope  the  same  peculiar  ana- 
tomical constituents.  In  shape  these  growths  afiect  the  spheri- 
cal, but  in  or  upon  the  bones  they  are  of  course  much  influenced 
by  the  pressure  which  they  encounter  as  they  spread ;  where- 
ever,  however,  they  escape  into  the  softer  tissues,  they  usually 
show  a  rounded  mass  which  is  limited  by  a  pretty  firm  capsule, 
and  which,  like  the  fibrous  tumors,  can  be  easily  enucleated 
from  the  bed  in  which  it  lies.  After  several  recurrences,  they 
are  apt  to  involve  more  extensively  the  surrounding  parts,  pene- 
trating between  the  muscles*,  adhering  to  the  bones,  and  deport- 
ing themselves  more  and  more  like  a  malignant  mass  each  time 
they  return.  Whether  this  form  of  tumor  ever  really  invades 
and  involves  in  its  substance  the  tissues  with  which  it  is  in 
contact,  I  do  not  know,  but  that  the  contrary  is  generally  the 
fact,  is  well  illustrated  by  one  of  Syme's  cases,  in  which  a  large 
tumor  on  the  chest,  which  was  the  last  of  five  or  six  recur- 
rences in  loco,  lay,  at  the  time  of  death,  among  the  muscles  so 
loosely  attached  that  it  might  have  been  removed  without  di- 
viding any  important  part,  "  as  a  common  fatty  tumor  might 
be." 

The  microscopic  characters  of  these  tumors  are  those  of 
very  closely-packed,  spindle-shaped  cells,  often  without  any, 
and  sometimes  with  a  considerable  amount  of  homogeneous, 
transparent,  intercellular  substance  (Fig.  73).  The  cells  con- 
tain a  nucleus,  which  is  situated  at  the  thickest  or  bulging  por- 
tion of  the  cell,  and  they  terminate  at  each  extremity  in  an 
elongated  point,  sometimes  branched,  which  varies  very  much 
in  its  length  and  tenuity.  These  cells  are  most  commonly 
arranged  with  some  regard  to  order,  so  that  in  well-developed 
specimens  a  laminated  or  fasciculated  tissue  results,  the  lines 
running  parallel  with  the  surface  of  the  tumor,  thus  increasing 
its  likeness  to  the  structure  of  a  proper  fibrous  tumor.  Vir- 
chow  also  notices  the  resemblance  to  epithelial  growth  which 
is  assumed  by  some  of  these  tumors  where  the  cells  are  large, 
and  where  the  intercellular  substance  is  absent  or  in  very  small 
quantity.  "With  the  elements  thus  enumerated,  we  have  often 


262 


TUMORS   OF  BONE. 


a  number  of  free  nuclei  scattered  through  the  tissue.  Of  these 
isolated  nuclei,  considered  by  many  as  an  original  and  essential 
element  of  the  formation,  Yirchow  speaks  very  emphatically, 

in  denying  to  them  any  histo- 
genetic  value,  he  considering 
them  in  all  cases  as  the  result 
of  destruction  of  the  original  cell 
with  liberation  of  the  nucleus, 
most  commonly  occasioned  by 
the  violence  done  in  the  prepa- 
ration for  the  microscope.  In 
many  of  these  tumors  we  have 
also,  associated  with  the  specific 
cell-formation,  a  certain  amount 
of  well -formed  connective  tis- 
sue, and  this  is  usually  arranged 
so  as  to  form  a  capsule  covering 
the  mass,  and  partitions  within 
separating  it  into  lobes  or  lob- 
ules more  or  less  distinct,  or  at 
least  forming  compartments  in 
the  internal  arrangement  of  the 

growth,  the  contents  of  which  compartments  sometimes  differ 
considerably  from  one  another  in  their  naked-eye  and  micro- 
scopic characters. 

In  the  bones,  these  tumors  are  found  almost  exclusively  in 
the  face  and  head.  Of  the  large  number  of  cases  collected 
by  Lebert,  only  thirteen  were  on  the  bones,  and,  of  these, 
one  was  developed  in  the  cranium,  four  in  the  superior  maxil- 
lary bone,  two  in  the  inferior  maxillary  bone,  and  five  were 
connected  with  the  alveolar  portion  of  these  bones  in  the  shape 
of  epulis.  He  gives  no  case  developed  in  any  other  bone  of 
the  skeleton  —  which  is  also  true  of  several  of  the  principal 
writers  on  this  subject — from  which  the  fair  inference  is  that 
they  are,  in  a  very  large  degree,  confined  to  the  bones  above 
mentioned.  Some  exceptions,  however,  do  present  themselves 
to  this  general  law.  I  shall  give,  farther  on,  two  cases,  in  one  of 
which  the  disease  commenced  in  the  malleoli,  and  another  in 
which  the  growth  sprang  from  the  transverse  process  of  a  cervi- 


Fio.  73.— (From  Bfflroth.) 


FIBROUS   TUMORS.  263 

cal  vertebra.  In  their  general  characters,  as  to  mode  of  growth, 
progress,  and  changes,  much  that  has  been  said  of  fibrous  tumors 
might  be  repeated,  and  their  histories,  up  to  a  certain  point,  are 
not  markedly  different.  Fig.  74  gives  a  very  good  idea  of  the 
external  appearances  of  one  of  these  tumors  developed  in  the 
lower  jawbone.  The  case  was  under  the  care  of  Mr.  Heath, 
from  whose  work  the  figure  is  copied.  It  was  of  slow  growth 
in  a  man  aged  thirty-two,  and  made  a  fungous  protrusion  into 


,     FIG.  74.— (From  Heath.) 

the  mouth  and  also  through  the  integuments  externally.  It  was 
removed  by  Mr.  Heath,  but  the  patient  died  exhausted  on  the 
sixth  day.  The  weight  of  the  mass  was  four  pounds  six  ounces. 
Mr.  Heath  gives  an  elaborate  account  of  the  minute  structure 
of  the  tumor,  which  terminates  with  this  statement :  "  The  gen- 
eral structure  of  the  tumor  is  that  usually  described  under  the 
head  of  osteo-sarcoma,  and  it  belongs  evidently  to  the  group  of 
simple  fibro-plastic  tumors,  but  differs  from  the  myeloid  fibro- 
plastics  in  the  equal  proportion  existing  between  the  cellular 
and  fibrous  elements." 

But,  in  their  final  tendencies,  the  tumors  belonging  to  this 
class  present  a  very  much  less  satisfactory  history  than  that 


264  TUMORS   OF  BONE. 

we  have  given  of  the  fibrous  tumor.  Their  evil  dispositions 
are  manifested  in  three  ways:  1.  In  a  tendency  to  reproduc- 
tion in  loco,  after  the  most  thorough  extirpation.  2.  In  a  dispo- 
sition to  reappear  in  neighboring  parts.  3.  In  generalization  of 
the  disease,  allowing  of  its  extension  to  other  and  distant  parts, 
after  the  most  malignant  fashion  of  true  cancer. 

Of  the  first  two  facts  in  the  history  of  these  tumors,  viz.,  a 
disposition  to  recurrence,  both  in  the  original  spot  and  in  its 
neighborhood,  but  little  needs  to  be  said.  They  are  the  striking 
facts  which  first  drew  attention  to  the  semi-malignity,  as  it  is 
called,  of  this  class  of  diseases,  and  they  are  illustrated,  most 
unhappily,  in  every  collection  of  cases  which  are  reported. 
With  regard  to  the  third  evil  feature  sometimes  observed  in 
these  tumors,  viz.,  their  generalization,  it  is  happily  exceptional 
and  rare.  Paget  speaks  of  no  case ;  Yirchow  describes  three 
very  interesting  and  well-marked  examples ;  and  Lebert  men- 
tions seven  as  having  been  seen  by  himself  and  by  others,  but 
of  these  only  two  were  tumors  of  bone.  In  these  cases  we 
have,  either  after  the  removal  of  the  original  growth,  or  during 
its  progress,  new  tumors  appearing  at  a  distance  from  the  pri- 
mary tumor,  which  may  multiply  at  various  points  and  in 
various  organs ;  these  secondary  or  metastatic  growths  as- 
suming the  prominent  importance,  and  finally  destroying  the 
patient  by  the  extent  of  their  involvement  of  organs  necessary 
to  life.  These  metastatic  growths  sometimes  take  place  along 
the  course  of  the  absorbent  vessels,  involving  the  glands  in 
their  progress,  but  sometimes,  also,  they  appear  in  distant 
organs,  when  we  can  conceive  of  but  one  mode  of  infection, 
viz.,  through  the  blood.  It  is  very  remarkable  that  in  almost 
every  case  in  which  an  autopsy  has  been  made,  where  any  in- 
ternal organ  has  been  found  infected,  the  lungs  have  been  either 
the  exclusive  or  the  principal  seat  of  the  morbid  deposit.  One 
example,  taken  from  Virchow,  will  be  a  sufficient  illustration  of 
the  disastrous  and  malignant  behavior  which  occasionally  char- 
acterizes this  disease : 

A  morocco  manufacturer,  aged  thirty-one,  shortly  after  a 
severe  attack  of  pleurisy,  observed,  growing  on  the  dorsum  of 
his  left  foot,  a  tumor  which  appeared  to  be  connected  only  with 
the  fibrous  structures  of  that  region,  and  soon  after  a  second 


FIBROUS  TUMORS.  265 

tumor  developed  itself  on  the  external  malleolus  of  the  same 
foot.  These  tumors  grew  rapidly,  and  about  two  months  after 
their  appearance  another  attack  of  pleurisy  came  on,  attended 
with  extreme  oppression  of  breathing,  without  cough  or  expec- 
toration, and  which  rapidly  proved  fatal.  The  tumors  of  the 
foot  were  found  to  involve  the  malleolus,  and  some  of  the  bones 
of  the  tarsus,  in  some  of  which  scarcely  any  thing  remained  of 
the  original  bone  but  the  periosteum  and  cartilage.  The  tumors 
showed  a  very  soft,  almost  diffluent  consistence,  much  like  en- 
cephaloid,  in  some  points  of  a  brownish-green  color,  in  others 
reddish  from  infiltration  of  blood.  Externally  they  showed 
numerous  lobes,  more  or  less  distinctly  separated.  In  the  pop- 
liteal space  was  found  a  gland,  enlarged  and  medullary  in  ap- 
pearance, and  the  same  was  true  of  several  of  the  lower  chain 
of  inguinal  glands.  In  the  anterior  mediastinum  was  found  a 
series  of  tumors  of  the  same  medullary  appearance.  The  right 
pleura  contained  a  large  sanguinolent  effusion,  and  over  its 
whole  surface,  soft,  very  delicate,  and  very  vascular  growths 
were  seen,  which  formed  almost  a  complete  layer,  covering  it 
entirely.  The  same  appearance  in  a  less  degree  presented  itself 
in  the  left  pleura.  In  the  lung  itself,  several  medullary  nodules 
of  a  gelatinous  consistence  were  found,  mostly  near  the  base 
of  the  left  lung,  while  near  its  summit  was  a  single  tumor,  the 
size  of  an  apple,  and  easily  enucleable  from  the  tissues  in  which 
it  lay.  The  right  lung  was  simply  compressed  by  the  pleuritic 
effusion.  All  these  masses  had  the  same  microscopic  structure. 
They  were  everywhere  composed  of  the  spindle-cells  of  small 
size,  with  an  intercellular  substance,  showing  very  little  trace 
of  fibres,  and  of  great  numbers  and  very  large  vessels.  The 
arrangement  of  the  cells  was  fasciculated. 

The  statement,  thus  presented,  of  the  malignant  behavior  of 
some  of  these  tumors,  is  not  by  any  means  to  be  received  as 
their  usual  history.  The  fact  is — and  it  is  in  this  fact,  now 
well  ascertained,  that  the  importance  of  the  anatomical  distinc- 
tion consists — that  the  larger  part  of  these  spindle-celled  tumors 
do  not  show  any  evil  dispositions,  and,  if  removed  early  and 
thoroughly,  do  not  return,  either  in  their  original  seat,  or  in 
any  other  part  of  the  body.  This  brings  these,  like  the  myeloid 
tumors,  fairly  into  the  class  of  benign  affections ;  and,  -while  we 


266  TUMORS   OF  BONE. 

recognize  the  fact  that  some  exceptional  instances  may  occur,  in 
which  a  semi-malignant  or  even  a  malignant  history  may  be 
realized,  we  may,  with  good  warrant,  hold  out  to  our  patients 
the  hope  and  expectation  that  a  thorough  extirpation  will  be 
followed  by  a  perfect  and  permanent  cure.  Even  the  local  re- 
currence is  not  necessarily  utterly  discouraging.  Many  cases 
are  on  record  where  several  operations  were  required  for  suc- 
cessive returns  of  the  disease,  and  where  finally  the  disposition 
to  the  recurrence  of  the  disease  seemed  to  be  exhausted,  and 
the  patients  have  maintained  for  many  years  perfect  health.  In 
one  singular  case  of  Mr.  Stanley's,  mentioned  by  Mr.  Paget, 
after  four  extirpations  by  Mr.  Stanley,  a  fifth  tumor  appeared 
and  grew  to  a  certain  size,  and  then  remained  stationary,  in 
which  condition  it  had  remained  at  the  time  of  the  report,  "  a 
long  time  without  in  any  way  interfering  with  the  patient's 
health."  Another  very  striking  case  is  reported  by  Mr.  Paget 
as  occurring  under  the  care  of  Dr.  Douglas  Maclagan,  in  which, 
"  after  four  recurrences  and  four  operations,  the  patient  has  re- 
mained five  years  well,  and,  at  the  present  time  (November, 
1862,  thirty  years  after  the  removal  of  the  first  tumor),  she  is 
in  perfect  health,  and  daily  follows  her  avocation  as  a  laundress. 
Since  1857  there  has  been  no  recurrence  of  the  tumor."  Simi- 
lar cases  are  recorded  by  other  observers. 

The  following  case  of  spindle-celled  fibroid,  attached  to  the 
transverse  process  of  the  fourth  cervical  vertebra,  illustrates 
many  of  the  points  to  which  we  have  referred,  and  is  in  itself 
so  wonderful  a  surgical  story,  and  terminated  in  such  a  com- 
plete and  surprising  success,  that  I  feel  warranted  in  giving  it 
in  full  detail : 

Mrs.  I.  ~N.  E.,  then  about  the  age  of  twenty-three,  consulted 
me  first,  March  26, 1866,  about  a  tumor  on  the  right  side  of  her 
neck,  which  had  been  growing  for  several  months,  and  which 
was  attended  by  a  great  deal  of  neuralgic  pain.  The  tumor  was 
about  the  size  of  a  large  hickory-nut,  pretty  firm  to  the  feel, 
situated  about  the  middle  of  the  neck,  a  little  behind  the  sterno- 
cleido-mastoid  muscle,  by  the  posterior  fibres  of  which  it  seemed 
to  be  overlapped.  It  had  grown  slowly,  and  without  apparent 
cause,  and,  although  there  was  no  history  of  any  other  glandular 
enlargement  in  any  other  part  of  the  neck,  I  felt  no  hesitation 


FIBROUS  TUMORS.  267 

i 

in  pronouncing  it  an  hypertrophied  lymphatic  gland,  and  in 
recommending  its  removal.  The  patient's  general  health  and 
condition  were  perfect. 

The  operation  was  performed  May  1,  1866.  The  tumor 
presented  itself  with  a  smooth,  enucleable  surface,  on  all  but  its 
deepest  parts,  and  there  it  was  attached  so  closely  to  the  trans- 
verse process  of  the  fourth  cervical  vertebra  that,  in  trying  to 
separate  it,  it  broke  and  discharged  a  whitish-yellow,  cheesy, 
semifluid  substance,  leaving  a  pretty  thick  but  not  very  tough 
sac  still  attached  to  the  bone  from  which  it  appeared  to  grow. 
This  sac  was,  as  thoroughly  as  possible,  snipped  with  the  scis- 
sors, or  dissected  with  the  knife,  from  its  attachments,  and  the 
cheesy  matter  carefully  wiped  from  the  wound.  Things  did 
not  go  well  after  this  operation.  The  wound  inflamed,  and 
matter  formed,  burrowing  down  the  neck  toward  the  clavicle. 
The  whole  region  became  extremely  sensitive,  and  the  subject 
of  severe,  apparently  neuralgic  pains.  She  lost  courage  as  well 
as  strength,  and  nothing  seemed  to  bring  her  up  until  she  went 
into  the  country,  when  the  wound  healed,  and  she  regained 
some  of  her  former  excellent  health. 

Microscopic  examination  of  the  tumor  was  reported  by  Dr. 
Delafield,  as  follows :  "  Tumor  was  broken  during  the  opera- 
tion, and  a  quantity  of  thin  fluid  escaped.  The  fragments  con- 
sisted of  a  grayishtissue,  resembling  that  of  a  lymphatic  gland, 
and  of  portions  of  cheesy  material.  The  firmer  portions  consist 
of  fusiform  cells  and  oval  nuclei  packed  closely  together  in  bands. 
Here  and  there  are  groups  of  rounded,  nucleolated  cells,  some 
resembling  gland-cells,  and  four  times  as  large.  In  other  places, 
round  cells  were  mixed  with  large  fusiform  cells.  There  was 
hardly  any  stroma.  The  cheesy  portions  consisted  of  the  same 
elements,  degenerated." 

After  her  return  from  the  country,  she  still  complained  of 
a  great  deal  of  pain  in  the  neck,  about  the  scar,  and  affecting 
all  the  muscles  of  the  region.  She  was  particularly  distressed 
at  night,  and  after  sleeping  found  it  exceedingly  painful  to  move 
the  head.  Some  fulness  remained  about  the  scar,  slowly  in- 
creasing, so  that  within  a  few  months  it  seemed  as  if  the  tumor 
were  forming  again.  Hoping  that  it  might  be  merely  a  tume- 
faction of  the  scar,  we  applied  leeches,  and  used  all  sorts  of  dis- 


268  TUMORS   OF  BONE. 

cutient  applications,  but  without  effect.  It  grew  gradually,  un- 
til, in  the  spring  of  1869,  it  seemed  as  large  as,  if  not  larger  than, 
before.  In  April,  1867,  about  a  year  after  the  first  operation, 
she  had  borne  a  healthy,  vigorous  child,  her  first,  and  had  been 
very  well,  except  the  local  complaints  about  the  neck,  during 
all  her  gestation  and  in  her  recovery  from  childbed.  During 
a  great  part  of  the  interval,  as  well  as  for  months  before  the 
first  operation,  she  had  used  iodine  very  largely,  both  locally 
and  internally,  without  any  perceptible  effect. 

During  the  latter  part  of  the  winter,  and  in  the  spring  of 
1869,  she  complained  of  numbness  of  the  right  arm  and  side, 
without  any  marked  impairment  of  motion,  and  this  seemed  to 
be  slightly  on  the  increase  up  to  the  time  of  the  second  opera- 
tion, which  was  performed  on  the  10th  of  April,  1869.  In  this 
operation,  which  exposed  a  tumor  very  similar  in  size  and  shape 
to  the  one  previously  removed,  we  experienced  more  difficulty 
in  detaching  the  deepest  parts  of  the  mass  from  the  transverse 
process.  Indeed,  the  morbid  growth  seemed  to  penetrate  be- 
tween the  transverse  processes  of  the  two  adjacent  vertebrae, 
where  we  followed  it  as  thoroughly  as  we  dared.  The  sac  had 
broken  as  before,  and  in  so  deep  a  wound  it  was  very  difficult 
to  distinguish  the  morbid  from  the  healthy  tissue,  and  still  more 
difficult  to  remove  it.  Great  pains  were  taken  to  remove  every 
thing  that  seemed  diseased,  but  it  was  impossible  not  to  feel 
that  some  might  have  been  left  behind.  The  actual  cautery  so 
near  the  spinal  cord  was  not  to  be  thought  of.  From  this  opera- 
tion she  recovered  rapidly,  and  without  accident.  The  numb- 
ness of  the  arm  disappeared,  and  she  felt  freer  from  pain,  and 
more  hopeful  of  entire  recovery  than  she  had  been  at  any  time 
since  the  first  appearance  of  the  disease. 

The  microscopic  report  of  the  tumor  was :  "  It  was  composed 
of  a  soft,  gelatinous  material,  with  some  cheesy  portions  enclosed 
in  a  fibrous  capsule.  It  was  broken  in  its  removal.  The  softer 
portion  consisted  of  a  gelatinous,  finely-granular  basement- 
substance,  in  which  were  embedded  large  numbers  of  round 
and  oval  nuclei." 

In  the  fall  of  1869  she  began  to  notice  a  return  of  the  old 
numbness,  now  in  both  hands,  and  in  the  right  foot.  This 
slowly  increased  until  she  found  she  was  obliged  to  give  up 


FIBROUS  TUMORS.  269 

sewing  altogether.  In  January,  1870,  she  could  no  longer  ar- 
range her  own  hair.  In  March  her  second  child  was  born,  after 
an  easy  and  rapid  labor.  By  this  time  she  had  become  very 
helpless,  but  improved  a  little  as  she  recovered  from  her  con- 
finement. Still,  she  was  very  clumsy  in  handling  the  baby, 
though  through  the  summer  she  managed  to  nurse  it,  and 
maintained  her  health  in  a  remarkable  degree.  She  suffered, 
however,  a  great  deal  from  a  fissure  of  the  anus,  which  a  very 
costive  habit  tended  much  to  increase.  Until  September,  she 
was  still  able  to  walk  about,  though  with  some  difficulty,  espe- 
cially in  the  right  leg  and  foot,  and  she  could  use  her  hands  in 
serving  herself  at  table,  the  right  better  than  the  left.  Early 
in  September  she  had,  without  apparent  cause,  an  attack  of  se- 
vere pain  in  the  muscles  of  the  neck,  with  great  difficulty  in 
moving  the  head.  This  pain  continued  more  or  less  at  inter- 
vals for  several  weeks.  Coincident  with  these  increased  pains, 
the  paralysis  increased  more  rapidly.  By  the  latter  part  of  No- 
vember she  had  lost  entirely  the  power  of  walking,  and  soon 
the  power  of  supporting  herself  upright,  even  for  a  few  mo- 
ments. Her  helplessness  now  became  complete,  and  by  the 
middle  of  January  she  was  entirely  paralyzed  in  all  parts  of  the 
body  below  the  neck.  By  the  time  of  the  last  operation,  the 
only  mo\7ements  she  could  make  were,  to  raise  the  right  hand 
a  few  inches  in  the  direction  of  flexion,  and  to  raise  the  legs  a 
similar  distance  by  drawing  up  the  thighs.  These  movements 
were  executed  very  slowly  and  painfully.  Every  movement  of 
the  body,  in  lifting  her  from  her  bed  or  sofa,  or  even  in  slightly 
changing  her  position,  gave  her  great  pain.  With  the  paralysis 
of  motion  there  was  a  paralysis  of  sensation,  which  could  be 
recognized  by  the  dividers  over  the  whole  body,  but  more  mark- 
edly in  the  hands  than  in  the  feet.  The  bowels  now  became 
more  obstinately  costive  than  ever,  and,  as  she  had  entirely  lost 
the  control  of  the  sphincter,  the  operation  of  medicine  was  at- 
tended with  great  trouble  and  inconvenience,  so  that  we  finally 
fell  into  the  way  of  giving  her  a  dose  of  castor-oil  once  a  week. 
In  the  mean  time  her  appetite  had  continued  pretty  good,  and 
the  general  nutrition  not  so  much  impaired  as  might  have  been 
anticipated.  She  was,  however,  very  despondent  about  herself, 
and  life  was  a  weary  burden.  By  this  time  the  tumor  had  again 


270  TUMORS   OF  BONE. 

slowly  developed,  and  was  nearly  as  prominent,  and  presented 
very  much  the  same  feel  that  it  had  done  previous  to  the  last 
operation. 

Dr.  Win.  H.  Yan  Buren  now  saw  her  in  consultation  with 
me,  and  the  question  presented  itself,  Could  any  thing  be  done 
to  relieve  her  by  another  operation  ?  The  evidences  of  press- 
ure on  the  cord,  probably  produced  by  an  extension  of  the  dis- 
ease within  the  spinal  canal,  were  so  unmistakable ;  the  prob- 
abilities, derived  from  the  fact  that  the  left  side  was  most 
affected,  that  the  pressure  was  from  a  growth  which  had  devel- 
oped itself  most  on  the  left  side,  were  so  great,  that  I  myself 
felt  hopeless  of  any  good  result  from  an  operation.  In  view, 
however,  of  a  partial  relief  being  possible  from  a  partial  re- 
moval of  the  compressing  cause,  and  taking  into  consideration 
the  utter  hopelessness  of  her  present  state,  it  was,  after  much 
hesitation,  decided  to  try  what  could  be  done  by  another  at- 
tempt at  removal. 

The  third  operation  was  performed  on  the  25th  of  January, 
1871,  Dr.  Yan  Buren  and  Dr.  H.  B.  Sands  assisting  me.  We 
had  determined  that  it  would  be  justifiable  to  remove  as  much 
of  the  transverse  process,  and  the  edge  of  the  lamina  of  the 
vertebrae,  as  would  give  access  to  the  point  of  pressure,  in  case 
this  point  seemed  at  all  accessible,  and  for  this  I  was  prepared. 
A  longer  incision  was  made  than  on  former  occasions,  parallel 
to  the  sterno-mastoid  muscle.  The  surface  of  the  tumor  was 
exposed,  and  then,  to  gain  more  freedom  in  the  deeper  nMnipu- 
lations,  another  incision  was  made  directly  backward,  at  right 
angles  to  the  first,  commencing  at  about  its  middle  point.  The 
more  superficial  portions  of  the  tumor  presented  very  much  the 
same  appearances  as  on  former  occasions,  and  were  quite  readily 
separable  by  enucleation  from  the  surrounding  parts.  "We  were, 
of  course,  extremely  anxious  not  to  break  the  sac  if  it  could  be 
helped,  and  succeeded  in  keeping  it  whole,  until  we  arrived  at 
its  deepest  parts,  which  we  found  to  dip  down  by  a  sort  of  ped- 
icle, between  the  transverse  processes,  and  to  reach  quite  down 
to  the  foramen  of  exit  of  the  cervical  nerve.  No  trace  of  that 
nerve  could  be  discovered  coining  out  alongside  of  the  pedicle 
of  the  tumor,  nor  any  sign  of  the  vertebral  artery,  whose  track 
from  one  transverse  process  to  another  we  had  now  crossed. 


FIBROUS   TUMORS.  271 

All  this  space  was  pretty  closely  filled  by  the  root  of  the  tumor, 
which,  as  we  carefully  isolated  it  from  surrounding  parts,  could 
be  distinctly  seen  to  enter  the  spinal  canal.  At  this  moment 
the  tumor  broke,  and  its  soft  contents  were  evacuated,  making 
it,  of  course,  more  difficult  to  identify  its  outline,  and  to  dis- 
criminate between  the  morbid  growth  and  the  normal  tissues. 
Proceeding  very  carefully,  however,  we  found  that  the  bony 
canal  had  been  much  enlarged  by  absorption,  from  the  pressure 
of  the  tumor,  and  it  soon  became  evident  that  through  this  open- 
ing, as  large  as  would  easily  admit  the  end  of  the  finger,  the 
external  tumor  communicated  with  a  growth  within  which  lay 
in  contact  with,  and  pressed  upon,  the  spinal  dura  mater.  As 
far  as  could  be  reached,  the  growth,  which  was  of  a  soft,  gummy 
consistence,  easily  friable  in  the  forceps,  was  removed  piece- 
meal as  thoroughly  as  possible.  After  all  was  got  away  that 
could  be  reached,  the  surface  of  the  dura  mater  of  the  cord  was 
left  bare  and  clean,  and  not  visibly  depressed  below  its  proper 
level.  We  could  still  perceive,  under  the  edge  of  the  bony 
opening,  that  some  of  the  morbid  material  existed,  but  it  was 
impossible  to  remove  any  more  through  the  opening  in  the 
bone,  and  the  great  depth  of  the  wound  seemed  to  make  any 
enlargement  of  the  bony  opening  an  undertaking  so  formidable 
that  we  shrunk  from  undertaking  it.  We  had,  moreover,  good 
ground  for  believing  that  the  great  mass  of  the  tumor  had  been 
removed,  and  that  the  thin  remaining  edge  which  lay  under 
the  bone  was  so  much  lacerated  and  contused  by  the  forceps, 
that  it  would  probably  be  destroyed  by  the  suppuration.  The 
wound  was  therefore  closed  by  fine  sutures,  leaving  a  small  por- 
tion at  the  junction  of  the  two  incisions  open ;  into  this  a  tent 
of  silk  thread  was  passed  fairly  down  to  the  bone,  with  the  view 
of  keeping  this  part  of  the  wound  open.  This  was  done  partly 
to  give  free  exit  to  any  fluids  forming  in  the  wound,  but  mainly 
to  give  a  chance  to  any  new  growth,  that  might  form,  to  develop 
itself  toward  the  surface  rather  than  into  the  spinal  canal. 

The  microscopic  report  of  the  tumor  is  :  "  It  has  the  same 
gross  appearances  as  at  the  first  occurrence.  The  basement- 
membrane  is  still  soft  and  hyaline,  but  contains  blood-vessels. 
The  nuclei  are  larger  and  more  numerous,  and  the  structure  is 
that  of  a  myxo-sarcoma." 


272  TUMORS   OF   BONE. 

January  26th. — Had  tolerably  good  rest  during  the  night, 
but  complains  of  severe  headache.  It  should  have  been  men- 
tioned that  before  the  operation  she  suffered  from  severe  pains, 
quite  irregular  in  their  recurrence,  in  the  thighs,  and  legs,  and 
back,  sometimes  very  severe,  and  sometimes  slight.  These 
pains  were,  at  night,  accompanied  often  with  sudden  and  vio- 
lent contractions  of  the  muscles,  flexing  up  the  thighs  on  the 
body,  and  the  legs  on  the  thighs,  the  spasm  of  the  muscles  very 
severely  increasing  the  pain,  and  often  entirely  depriving  her 
of  sleep.  She  complained  this  day  of  increased  pain  on  the 
outside  of  the  left  thigh,  and  in  the  right  leg.  No  contractions 
of  muscles.  She  was  sensible  of  greater  power  over  the  whole 
body,  and  found  she  could  move  the  toes  a  little,  and  slightly 
raise  the  right  hand. 

January  21th. — Severe  pain  in  left  arm,  and  distressing 
headache.  Improvement  in  the  use  of  limbs ;  can  raise  left 
arm. 

January  28th. — Good  night's  rest,  and  has  very  little  pain. 
She  begins  to  feel  hungry.  Toward  evening  complained  of 
numbness  all  over  the  body,  with  increase  of  pain  in  the  left 
thigh.  No  contractions  of  limbs. 

January  29th. — Sleepless  night.  Complains  of  dark  objects 
flitting  before  her  eyes,  and  seems  to  herself  to  be  carrying  on 
both  sides  of  a  conversation.  Has  severe  headache  and  burning 
sensation  in  the  eyes.  Pulse  slightly  accelerated,  skin  natural. 
She  feels  her  body  very  hot  while  the  feet  are  cold.  Gave  a 
full  dose  of  morphine  at  bedtime. 

January  30th. — Not  much  relief  from  anodyne.  Great 
pain  to-day  down  the  spine  and  left  leg.  Any  bending  of  the 
spine  in  changing  her  pillow  or  position  gives  dreadful  pain,  as 
if  the  back  were  being  broken.  In  making  any  change  of 
position  the  hips  and  head  must  be  raised  on  the  same  level. 
Wound  doing  well ;  has  healed  mainly  by  the  first  intention, 
the  central  portion  discharging  a  watery  pus.  By  drawing  up 
her  knees,  she  finds  that  she  can  raise  her  hips  from  the  bed  for 
the  first  time  in  about  four  months.  Toward  evening,  severe 
pain  in  side  and  back,  from  changing  her  position,  continuing 
most  of  the  night. 

January  31st. — Chloral  substituted  for  morphine,  but  with- 


FIBROUS    TUMORS.  273 

out  producing  any  satisfactory  sleep.  She  is  much  reduced  in 
flesh,  pulse  feeble,  and  about  100.  The  skin  sometimes  hot 
and  dry,  and  sometimes  relaxed  ;  the  feet  generally  cold.  The 
thin  discharge  from  the  wound  is  in  great  abundance,  and,  on 
examination,  is  found  to  be  a  pure,  white,  transparent  water, 
which  trickles  from  the  opening  in  such  quantities  as  to  soak 
through  the  sheets  and  pillows,  and  to  keep  her  bed  constantly 
wet.  This  can  only  be  the  cerebro-spinal  fluid,  and  its  point 
of  exit  must  be  the  prolongation  of  the  dura  mater  which  cov- 
ered the  spinal  nerve  as  it  left  the  canal,  and  which  sheath  must 
have  been  opened  in  the  operation.  It  is  probably  increased  in 
quantity  by  the  spinal  meningitis,  from  which  she  is  evidently 
suffering.  She  suffers  greatly  from  pain,  constant  in  the  head, 
migratory  in  the  trunk  and  limbs,  and  also  from  great  soreness 
and  sensitiveness  of  the  surface,  sometimes  in  one  region  and 
sometimes  in  another,  which  makes  it  very  painful  and  difficult 
for  her  to  move,  or  to  be  moved.  She  was  now  kept  systemati- 
cally under  the  full  influence  of  morphine,  of  which  she  took, 
however,  only  a  moderate  quantity,  say  five  to  ten  drops  every 
four  hours. 

February  ^.d, — Still  suffering  greatly.  Complains  of  a  con- 
stant sensation  of  fatigue ;  cannot  bear  any  light  or  noise.  This 
evening,  in  consequence  of  changing  her  position,  violent  con- 
tractions of  the  left  leg,  with  excessive  pain,  were  produced, 
recurring  at  intervals  during  the  night.  The  watery  discharge 
very  abundant. 

February  4th. — A  better  night,  and  general  improvement. 
Can  use  all  her  limbs  more  freely,  and  can  almost  turn  over  in 
bed  alone.  Cannot  raise  the  head  and  shoulders,  by  bending  the 
spine,  without  giving  severe  pain  in  left  leg.  From  this  time 
improvement  went  on  steadily  for  a  few  days,  and  was  then 
interrupted  by  a  severe  attack  of  headache,  and  pain  in  the 
back  and  limbs,  with  some  fever.  This  subsided  in  a  few  days, 
and  similar  attacks  recurred  several  times,  at  intervals  of  a  week 
or  ten  days,  each  attack  becoming  less  severe,  and  in  the  inter- 
val a  greater  improvement  being  attained.  The  cerebro-spinal 
fluid  continued  to  trickle  away  till  toward  the  end  of  Febru- 
ary, when  it  ceased  for  a  few  days,  to  begin  again  as  freely  as 
ever.  About  the  first  of  March  it  ceased  again,  and  finally. 
18 


274  TUMORS  OF  BONE. 

No  apparent  connection  could  be  traced  between  the  flow  and 
any  of  her  symptoms. 

By  the  first  of  March  the  paralysis  had  pretty  much  disap- 
peared in  every  part  of  the  body.  There  was  still  some  still- 
ness in  moving  the  fingers,  and  some  want  of  precision  in 
taking  hold  of  small  objects,  but  hardly  more  than  could  be 
accounted  for  by  the  long  disuse  of  the  muscles.  On  the  llth 
of  March  she  was  carried  down-stairs  to  dinner,  and  on  the  13th 
took  a  drive  of  three-quarters  of  an  hour.  She  is  quite  thin, 
but  free  from  pain,  eats  well,  and  sleeps  with  the  help  of  a 
grain-pill  of  opium. 

May  1st. — Mrs.  E.  called  at  my  office  to  say  that  the  wound 
had  entirely  healed  over  the  tent,  which  on  examination  I  found 
to  be  the  case.  There  is  no  swelling  or  tenderness  about  the 
cicatrix,  and  I  advised  that  the  tent  be  left  undisturbed.  She 
is  perfectly  well,  gaining  flesh  and  appearance,  no  symptom  of 
paralysis  remaining,  excepting  that  the  limbs  get  asleep  more 
easily  than  in  health.  She  walks,  rides,  sews,  and  does  every 
thing  that  she  ever  did  with  a  rapidly-increasing  facility  and 
perfection.  Menstruation  is  regular,  as  also  the  action  of  the 
bowels.  The  old  symptoms  of  fissure  give  her  but  little  incon- 
venience. Appetite  and  digestion  perfect. 

January r,  1872. — Mrs.  E.  continues  perfectly  well. 

The  proportion  of  cases  in  which  recurrence  takes  place 
after  operation  has  been  carefully  studied  by  Lebert.  He  gives 
an  account  of  sixty-three  cases,  situated  in  all  parts  of  the  body, 
in  which  operation  had  been  performed,  of  which  thirteen  cases 
were  followed  by  one  or  more  recurrences.  Of  these  thirteen, 
six  were  instances  in  which  the  operation  had  been  imperfect 
from  the  situation  of  the  tumor,  or  from  its  extent,  and  in 
which,  therefore,  it  might  be  inferred  that  the  return  of  the 
growth  was  only  a  continuation  of  its  former  existence,  rather 
than  a  new  formation.  Of  the  remainder,  two  were  somewhat 
mixed  in  their  character,  or  doubtful  as  to  their  nature ;  leaving, 
out  of  sixty-three  cases  operated  on,  only  five  frank,  unequivo- 
cal relapses  after  complete  ablation  of  the  original  tumor. 
None  of  these  five,  however,  were  tumors  of  the  bone.  Of 
course,  such  statistics  as  these  can  be  of  little  value  in  settling 
the  actual  proportion  of  recurrences  to  permanent  cures,  be- 


FIBROUS  TUMORS.  275 

cause  the  element  of  time  is  necessarily  imperfectly  stated  in 
the  calculation.  How  many  of  these  patients  would  have  had 
a  return  of  the  disease,  if  longer  time  had  been  given  to  the 
observation,  cannot  of  course  be  ascertained.  But,  neverthe- 
less, the  statement  is  of  interest,  as  giving  a  general  idea  of 
how  frequent  recurrence  is  within  a  few  years  of  the  time  of 
operation,  and  it  is  fair  to  hope  that  a  relapse  so  long  delayed 
indicates  a  permanent  cure  in  a  good  proportion  of  cases — this 
hope  strengthening  with  every  year  of  freedom  from  the  signs 
of  return.  Some  of  Lebert's  cases  had  been  under  observation 
for  a  long  period  after  operation.  Three  patients  he  speaks  of 
whom  he  had  watched  for  periods  varying  from  twelve  to  fifteen 
years.  He  also  gives  the  duration  of  thirty-five  cases  where 
the  disease  had  been  observed  from  its  beginning  to  its  termi- 
nation, either  in  operation  or  death,  which  he  thus  tabulates : 


Existing  from    1     to     2  years  in 
"            "       2     to     3       "     in 
"            "       3    to    4      "     in 
"            "       4    to    5       "     in 
"            "       5     to     6       "     in 

5 
5 
5 

4 
4 

cases. 

u 
II 

it 
(( 

u 

for 

9  years                in 

1 

case. 

II 

it 

10 

in 

3 

cases. 

11 

M 

12 

*                   in 

1 

case. 

u 

II 

15 

'                   in 

2 

cases. 

u 

U 

18 

'                   in 

1 

case. 

u 

u 

20 

'                   in 

3 

cases. 

u 

over  20 

4                   in 

1 

case. 

35 

"With  regard  to  the  comparative  frequency  of  generalization 
of  the  disease,  he  does  not  attempt  any  statistical  statement,  and 
I  have  met  with  none  in  any  other  writer.  He  simply  states  that 
he  has  known  of  seven  cases,  of  which  he  gives  more  or  less 
full  details,  from  his  own  observation,  and  that  of  others.  Of 
these  seven,  only  two  were  bone-tumors,  one  of  the  bones  of  the 
knee,  and  one  of  the  bones  of  the  tarsus. 


276  TUMORS  OF  BONE. 

CHAPTER  IY. 

MYELOID     TUMORS. 

THE  name  of  myeloid  (marrow-like)  was  given  by  Mr.  Pa- 
get  to  a  class  of  tumors  which  present  as  their  principal  ana- 
tomical constituents  the  elements  of  the  medulla  or  marrow  of 
the  bones.  The  English  writers  generally  accept  this  name  for 
a  class  of  diseases  which  has  a  most  unequivocal  character,  and 
which  seems  to  be  as  well  marked  and  as  distinctive  as  the  car- 
tilaginous or  the  bony  class  of  tumors.  The  French  writers, 
following  M.  Eugene  Nelaton,  prefer  the  clumsy  term  of  tii- 
meur  myeloplajdque,  or  tumeur  d  myeloplaxes.  To  Robin 
seems  to  be  due  the  credit  of  having  first  made  the  distinction 
of  a  certain  class  of  tumors  whose  principal  elements  consist 
of  the  elements  of  the  normal  medulla.  In  the  Comptes  Ren- 
dus  of  the  Societe  de  Biologic  for  October,  1849,  M.  Robin, 
after  giving  an  account  of  certain  anatomical  elements  of  the 
normal  medulla,  goes  on  to  state  that  these  elements  are  some- 
times found  to  be  the  sole  constituents  of  certain  tumors ;  of 
which  tumors  he  then  proceeds  to  give  some  description,  and 
ends  his  communication  by  again  calling  attention  to  the  fact 
that  these  tumors  are  composed  essentially  of  an  aggregation 
of  these  peculiar  elements  of  the  marrow,  which  he  now  for 
the  first  time  brings  to  the  notice  of  the  society.  M.  Lebert 
had  already  noticed  that  certain  tumors,  heretofore  deemed 
cancerous,  did  not  show  the  clinical  history  of  cancer,  and 
these  he  had  placed  in  a  new  class,  calling  them,  from  their 
histological  elements,  fibro-plastic  tumors.  Among  these  were 
many  which  had  the  peculiar  marrow-like  cells  in  great  abun- 
dance, but  these  Lebert  does  not  allude  to  as  distinctive ;  and  it 
was  not  till  Robin  described  them  as  the  constituent  elements 
of  the  normal  marrow,  that  their  significance  was  understood. 
Robin  immediately  recognized  these  new  elements  as  the  same 
found  in  the  tumors  which  he  and  Lebert,  it  would  seem,  had 
seen  together ;  and  to  him,  therefore,  and  not  at  all  to  Lebert, 
belongs  the  credit  of  the  discovery.  Some  confusion  has  thus 
arisen,  and  a  proper  discrimination  has  not  always  been  made 


MYELOID   TUMORS.  277 

between  the  two  classes  of  diseases,  viz.,  the  tumors  composed 
of  fibro-plastic  cells,  and  those  composed  of  marrow-like  cells. 
Mr.  Paget,  usually  so  accurate,  has  fallen  somewhat  into  this 
confusion,  and  describes  the  myeloid  tumor  and  the  fibro-plastic 
as  if  they  were  one,  while  the  fact  is,  they  are  as  different  in 
their  anatomical  constitution  as  bone  and  cartilage  or  any  other 
two  classes  of  tumors.  It  is  true  that  the  fibro-plastic  elements 
are  sometimes  mingled  with  the  true  myeloid,  but  this  is  true 
of  all  other  classes  of  tumors,  and  does  not  forbid  a  discrimina- 
tion where  one  or  other  element  very  greatly  predominates. 

And  here,  perhaps,  the  interest  which  at  the  present  time 
attaches  to  the  subject  may  justify  a  sketch  of  the  normal  con- 
stituent of  the  marrow,  the  presence  of  which,  in  greater  or  less 
abundance,  gives  the  character  to  the  class  of  tumors  which  we 
are  describing.  I  know  of  no  description  so  minute  and  com- 
plete as  that  of  M.  E.  Nelaton,  who  has  published  an  elaborate 
thesis  on  this  subject,  founded  on  the  careful  observation  and. 
study  of  forty-seven  cases,  nine  of  which  came  under  his  own 
eye.  He  says,  in  speaking  of  the  normal  marrow-cells  (myelo- 
plaxes),  that  they  exist  in  all  the  vertebrata  and  at  all  ages ;  but 
they  form  only  a  small  part  of  the  whole  medullary  substance. 
They  are  found  more  easily  in  the  foetus,  and  in  very  young 
subjects,  because  they  are  not  obscured  by  the  adipose  develop- 
ment which  predominates  in  later  years.  Their  favorite  situa- 
tion is  close  to  the  bone-surfaces  rather  than  in  the  midst  of  the 
marrow,  and  they  are  also  sometimes  seen  in  the  Haversian 
canals.  Their  form  is  variable.  They  may  be  round,  oval,  tri- 
angular, elongated,  hour-glass-shaped,  or  curved  on  themselves. 
Their  almost  uniform  tendency  is  to  be  flat ;  so  much  so  as 
to  give  them  the  character  of  plates  (plaques)  rather  than  of 
masses.  Their  dimensions  are  as  variable  as  their  forms,  ex- 
tending from  0'" '"  03  to  0'" '"  08  or  0'" '"  10.  Their  thick- 
ness is  from  one-quarter  to  one-half  their  breadth,  and  some 
are  seen  no  larger  than  blood-globules.  Their  color  is  grayish, 
sometimes  a  little  yellowish. 

With  regard  to  their  structure,  they  seem  to  be  composed 
of  a  homogeneous  mass  without  color,  uniformly  pervaded  by 
very  fine  grayish  granules,  soluble  in  acetic  acid,  and  mingled 
sometimes  with  granules  of  a  yellow  tint.  In  the  thickness  of 


278  TUMORS  OF  BONE. 

this  str'oma  exists  a  number  of  nuclei,  ovoid  and  transparent, 
and  containing  one  and  sometimes  two  nucleoli.  The  number 
of  nuclei  varies  from  five  to  fifteen  ordinarily,  in  exceptional 
cases  from  one  to  sixty.  They  are  irregularly  distributed 
through  the  mass  of  the  plate,  but  are  usually  accumulated  at 
or  near  the  centre. 

A  second  variety  of  these  medullary  bodies  differs  from 
that  described,  in  several  particulars.  They  are  smaller,  more 
regular  in  size  and  shape,  not  flat,  but  round  or  oval.  They 
have  one  or  two  and  sometimes  no  nuclei,  which,  when  they 
exist,  are  ovoid  in  shape,  and  have  a  distinct  nucleolus.  They 
are  usually  less  numerous  than  the  larger  flat  plates,  and,  being 
smaller,  are  less  easily  found.  In  other  respects  their  structure 
corresponds  with  the  large  plates. 

These  anatomical  elements  had  been  seen  by  several  ob- 
servers in  certain  tumors  which  they  were  engaged  in  studying, 
but  their  character  was  misinterpreted,  simply  because  the  key 
to  their  explanation  had  not  been  supplied,  as  it  afterward  was 
by  Robin's  discovery  of  these  peculiar  bodies  as  normal  ele- 
ments of  the  marrow.  Thus  M.  Lebert,  seeing  these  myelo- 
plaxes  scattered  through  some  of  the  tumors  he  had  named 
fibro-plastic,  embraced  the  notion  that  they  were  parent-cells 
out  of  which  were  generated  the  fibro-plastic  cells  of  which  the 
tumor  was  essentially  composed.  Under  this  view  he  gave 
them  the  name  of  fibre-plastic  mother-cells,  thus  ranging  them 
very  easily  under  his  favorite  theory  of  the  formation  of  the 
fibro-plastic  elements.  Such  erroneous  views  of  the  significance 
of  these  bodies  are  now  happily  corrected  by  M.  Robin's  dis- 
covery, and  all  the  authorities  agree  in  accepting  it  as  the  satis- 
factory solution  of  the  vexed  problem.  It  will  readily  be  per- 
ceived how  much  importance  this  study  of  the  microscopic 
characters  of  these  tumors  has  in  settling  the  important  ques- 
tion of  their  homologous  or  heterologous  character ;  and  it  is 
eminently  satisfactory  to  find  that,  in  tumors  of  a  manifestly 
benign  character,  the  elements  which  heretofore  have  been  con- 
sidered at  least  doubtful,  have  now  been  ranged  positively  un- 
der the  head  of  the  normal  constituents  of  the  body.  Still 
further,  it  seems  very  much  in  accordance  with  the  regularity 
of  true  science  that  this  discovery  completes  our  catalogue  of 


MYELOID   TUMORS.  279 

the  homologous  bone-diseases,  giving  us  the  tumors  composed 
of  the  elements  of  cartilage,  of  bone,  of  the  fibrous  tissue  of 
the  periosteum,  and  of  the  medulla,  all  of  which  we  might  ex- 
pect to  belong,  and  all  of  which  we  find  to  belong,  to  the  class 
of  benign  affections. 

On  this  point,  which,  after  all,  is  the  most  interesting  and 
important  one  connected  with  the  study  of  the  disease,  the 
testimony  of  the  best  observers  is  unhesitating  and  uniform. 
Mr.  Paget's  whole  chapter  on  Myeloid  Tumors  is  devoted  to 
show  that,  as  a  general  rule,  they  are  benign  in  their  nature, 
and  that,  if  thoroughly  removed,  the  likelihood  of  their  return 
is  extremely  small.  Nelaton  says :  "  The  '  tumeurs  a  myelo- 
plaxes'  (especially  those  of  the  typical  variety)  deserve,  in 
virtue  of  their  habitual  localization,  and  almost  to  the  same 
degree  as  the  lipomas,  the  fibromas,  and  the  enchondromas,  to 
be  classed  among  the  benign  tumors."  "Virchow,  while  he  is 
not  willing  to  acknowledge  the  myeloid  as  generally  benignant, 
gives  no  case  of  his  own  in  which  well-marked  myeloid  disease 
has  been  accompanied  with  generalization,  and  says  in  discuss- 
ing the  value  of  the  different  anatomical  elements  of  sarcoma : 
"The  size  of  the  cells  is  not  without  importance.  All  the 
sarcomata  with  small  cells  are  more  dangerous  than  those  with 
large  cells.  The  soft  sarcomata  with  the  gigantic  multinuclear 
cells  give  even  a  prognostic  comparatively  very  favorable."  If 
to  this  be  added  his  avowal  of  the  almost  uniform  benignity  of 
the  myeloid  epulis,  and  of  the  tumors  of  the  jaws  in  general, 
we  may  accept  him  as  an  unwilling  but  a  strong  witness  to  the 
general  pathological  law  that  myeloid  tumors  are  essentially 
benignant.  Billroth  says  :  "  Central  osteo-sarcomata  (myeloid 
tumors)  are  usually  solitary,  very  rarely  generally  infectious." 
Cornil  and  Ranvier  say :  "  Among  the  myeloid  sarcomata  those 
which  resemble  absolutely  the  marrow  of  the  bones  are  more 
benign  than  those  in  which  we  find  parts  representing  the  tis- 
sue of  the  encephaloid  or  fasciculated  sarcoma.  It  is  essential 
to  note  these  complications  and  their  value  in  prognosis,  which 
will  explain  why,  for  example,  the  tumors,  which  some  authors 
still  call  '  tumeur  a  myeloplaxes,'  may  not  be  always  regarded 
as  benign." 

The  occasional  malignity   of  myeloid  growths    has  been 


280  TUMORS   OF  BONE. 

frankly  admitted,  both  by  Mr.  Paget  and  Eugene  Nelaton ; 
and  it  is  unfortunately  illustrated  in  the  experience  of  every 
surgeon  who  deals  with  many  of  these  interesting  tumors. 
Nelaton  seems  to  be  the  special  apologist  for  benignity  of  the 
myeloid  disease,  while  Yirchow,  though  hardly  acknowledging 
the  fact  of  its  usual  benignity,  alludes  to  several  examples  in 
which  the  disease  has  terminated  life,  with  all  the  malignant 
characters  which  we  generally  regard  as  characterizing  the 
worst  forms  of  cancer.  He  gives  no  case  of  his  own,  however. 
One  of  the  earliest  cases  reported  in  New  York  was  one  of  a 
tumor  of  the  lower  end  of  the  humerus,  in  which  the  microscop- 
ical appearances  were  carefully  observed  by  Dr.  H.  B.  Sands, 
and  were  unequivocally  myeloid.  This  patient  was  amputated 
by  Dr.  Sands,  and  made  a  very  satisfactory  and  apparently 
perfect  cure.  He  remained  well  for  at  least  two  years,  and 
then  a  return  of  the  affection  occurred,  of  which  he  finally  died. 
I  regret  that  I  am  not  able  to  get  any  particulars  of  the  relapse. 
Mr.  Paget  recounts  two  cases,  one  by  Mr.  Stanley,  and  one  by 
Mr.  Laurence,  in  which  after  removal  the  disease  returned  in 
distant  parts,  and  proved  fatal.  Mr.  Mitchill  Henry,  Mr.  Cooper 
Foster,  Drs.  Cock  and  Wilkes,  have  each  given  a  record  of  one 
or  more  cases  in  which  fatal  metastasis  has  occurred  after  re- 
moval, and  in  which  the  recurrent  tumor  has  been  shown  by 
the  microscope  to  be  of  the  same  nature  as  the  original  growth. 
If  to  these  cases  we  add  those  in  which,  after  complete  extirpa- 
tion, the  disease  is  reproduced  in  loco,  we  are  forced  to  acknowl- 
edge that  the  myeloid  tumor  shows,  in  certain  cases,  a  character 
of  inveteracy  and  malignancy  which  must  always  be  taken  into 
the  account  in  making  our  prognosis.  Nevertheless,  we  are 
warranted,  from  the  more  kindly  behavior  of  the  great  propor- 
tion of  the  cases,  in  regarding  the  myeloid  as  an  essentially  be- 
nignant affection — one  in  which,  as  stated  above,  a  thorough 
extirpation,  if  performed  early,  gives  a  good  hope  of  a  perfect 
cure,  and  one  in  which  the  evil  course  and  malignant  termina- 
tion are  rare  and  exceptional,  thus  bringing,  by  the  bad  be- 
havior of  a  few  members,  a  certain  amount  of  discredit  on  an 
otherwise  well-behaved  and  reputable  family. 

A  fact  which  seems  to  stand  alone  in  connection  with  these 
tumors  is  their  occasional  spontaneous  disappearance.     Mr.  Pa- 


MYELOID  TUMORS.  281 

get,  in  giving  an  account  of  one  of  Mr.  Stanley's  cases,  mentions 
that  the  patient,  from  whom  the  right  upper  jaw  was  removed 
for  myeloid  disease,  had  a  similar  tumor  on  the  left  jaw  and  on 
the  parietal  bones.  He  says :  "  The  patient  recovered  perfectly 
from  the  effects  of  the  operation ;  and,  to  every  one's  surprise, 
the  tumor  on  the  left  upper  jaw,  which  had  been  in  all  respects 
like  that  removed  from  the  right  side,  gradually  disappeared. 
It  underwent  no  change  of  texture,  but  simply  subsided.  The 
swellings  on  the  parietal  bones,  also,  the  nature  of  which  was 
not  ascertained,  cleared  away ;  and  when  the  patient  was  last 
seen,  a  few  months  ago,  she  appeared  completely  well,  and  no 
swelling  could  be  observed."  This  disappearance,  by  sponta- 
neous subsidence,  has  been  occasionally  observed  in  tumors  of 
the  soft  parts ;  and  even  cancerous  disease  has,  in  rare  instances, 
been  apparently  absorbed  and  removed,  as  illustrated  in  a  case 
alluded  to  under  the  malignant  diseases  of  bone ;  but  this  dis- 
appearance of  tumors  formed  in  the  bones  is,  I  believe,  ex- 
tremely uncommon. 

The  myeloid  tumors,  like  the  osseous  and  cartilaginous,  most 
commonly  affect  the  bones,  yet,  like  them,  occasionally  are 
found  growing  independent  of  them.  The  alveolar  portions  of 
the  upper  and  lower  jaw  seem  to  be  their  favorite  seat,  but  they 
also  occur  in  the  head  of  the  tibia,  in  the  condyles  of  the  femur, 
and  more  rarely  in  other  bones  which  contain  a  large  propor- 
tion of  medullary  or  cancellous  tissue.  Fig.  75  is  taken  from 
Paget,  and  represents  a  myeloid  tumor  of  which  he  gives  a  very 
interesting  history.  It  shows  the  growth  of  the  mass  both  ex- 
ternally and  internally  from  the  bones  of  the  vault  of  the  crani- 
um. It  produced  death  by  pressure  on  the  brain.  They  some- 
times grow  from  the  surface,  often  from  the  interior  of  the  bones, 
not  unfrequently  in  the  medullary  canal  itself,  when  it  some- 
times happens  that  the  line  of  demarcation  between  the  sound 
medulla  and  the  morbid  growth  cannot  be  at  first  sight  recog- 
nized. These  tumors  are  usually  single,  occasionally  multiple 
on  the  same  bone,  with  a  smooth,  rounded  surface,  projecting 
equally  in  all  directions  from  their  base  of  attachment,  when 
they  grow  from  the  surface  of  the  bone.  Their  substance  varies 
from  a  firm,  almost  cartilaginous  consistence,  down  to  a  softness 
equal  to  that  of  fresh  granulations.  Their  color  is  remarkable. 


282  TUMORS  OF  BONE. 

Sometimes  the  whole  cut  surface  presents  a  deep,  ruddy  hue ; 
often  even  a  darkish  brown.  Perhaps  more  commonly  a  pinkish 
or  a  greenish  tint  pervades  the  whole  mass,  though  varying  in 
depth  at  different  points.  Interspersed  through  the  tumor  are 
spots  or  blotches  of  deep  red  or  brown  color,  looking  as  if  ex- 


FIG.  75.— (From  Paget ) 

travasation  of  blood  had  taken  place  from  small  raptured  ves- 
sels. These  colorations  of  the  tumor  are  the  most  striking  and 
characteristic  features  to  the  naked  eye,  but  the  microscopical 
examination  gives  still  more  distinctive  characters. 

Thus  we  find  the  whole  tumor  made  up  of  the  elements 
which  normally  exist  in  the  medulla.  Mr.  Paget  thus  describes 
them:  1.  "Cells  of  oval,  lanceolate,  or  angular  shapes,  or  elon- 
gated and  attenuated  like  fibre-cells,  or  caudate  cells,  having 
dimly-dotted  contents,  with  single  nuclei  or  nucleoli.  2.  Free 
nuclei,  such  as  may  have  escaped  from  the  cells ;  and  among 
these  some  that  appear  enlarged  and  elliptical,  or  variously 
angular,  or  are  elongated  toward  the  same  shapes  as  the  lanceo- 
late and  caudate  cells,  and  seem  as  if  they  were  assuming  the 
characters  of  cells.  3.  The  most  peculiar  form  :  large,  round, 
oval,  or  flask-shaped,  or  irregular  cells  and  cell-like  masses  or 
thin  disks,  of  clear  or  dimly-granular  substance,  measuring  from 
TOT  to  -nnnr  of  an  inch  in  diameter,  and  containing  from  two  to 
ten  or  more  oval,  clear,  and  nucleolated  nuclei.  Corpuscles  such 
as  these,  irregularly,  and  in  diverse  proportions,  embedded  in  a 


MYELOID   TUMORS. 


283 


dimly-granular  substance,  make  up  the  mass  ot  a  myeloid  tumor. 
They  may  be  mingled  with  molecular,  fatty  matter ;  or  the  mass 
they  compose  may  be  traversed  with  filaments,  or  with  bundles 
of  connective  tissue  and  blood-vessels ;  but  their  essential  fea- 
tures (and  especially  those  of  the  many-nucleated  corpuscles)  are 
rarely  obscured."  Figs.  76,  77  show  the  appearance  of  these 
various  cells. 

M.  E.  Kelaton,  in  describing  the  microscopic  characters  of 
these  tumors,  says  they  are  composed — "  1.  Of  a  great  quantity 


FIG.  76.— (From  Cornil  and  Ranvier,  after  Virchow.) 

of  myeloplaxes,  the  fundamental  elements  which,  by  their  pre- 
dominance, characterize  the  tissue.  2.  Of  certain  accessory 
elements,  such  as  fibrous  or  nbro-plastic  cells,  amorphous  mat- 
ter, molecular  granules,  fatty  granules,  free  nuclei,  some  medul- 
locelles,  some  capillary  blood-vessels ;  besides  these  the  micro- 
scope can  distinguish  in  the  preparation  a  certain  number  of 
blood-globules,  sometimes  coloring-matter  in  a  free  state,  and 


284 


TUMORS   OF   BONE. 


sometimes  also  a  small  amount  of  osseous  substance.  It  will  be 
observed  that  these  are  almost  the  same  elements  as  those  which 
compose  the  tissue  of  the  medulla  of  the  bones,  but  with  this 
difference — a  difference  of  capital  importance  in  histological 
study — that  the  accessory  element  has  here  become  the  princi- 
pal, and  conversely." 


FIG.  77.— (From  Cornil  and  Ranvier.) 

It  would  seem  as  if  there  existed  a  pretty  well-marked  rela- 
tion between  the  varying  proportion  of  these  elements  and  the 
physical  qualities  of  the  tumor.  Thus,  in  those  specimens  where 
the  fibrous  or  fibro-plastic  elements  abound,  the  parenchyma 
of  the  tumor  is  firmer;  where  the  marrow-cells  are  greatly  pre- 
dominant, the  tumor  is  softer ;  so  soft  as  sometimes  to  be  almost 
a  diffluent  pulp.  In  the  same  way  the  color  seems,  from  the 
observations  of  Eugene  Nekton,  to  depend  upon  the  proportion 
of  the  marrow-cells  to  the  other  constituents ;  these  marrow- 


MYELOID  TUMORS.  285 

cells,  according  to  him,  possessing  the  peculiar  intrinsic  color 
which  marks  these  tumors,  and  this  entirely  independent  of 
blood  either  contained  in  the  vessels,  or  extravasated. 

The  history  of  myeloid  tumors  is  generally  one  of  slow  and 
painless  growth.  Most  commonly  originating  from  no  apprecia- 
ble cause,  their  increase  is  regulated  somewhat  by  their  situa- 
tion, those  within  the  bones  developing  more  slowly,  those  on 
the  surface,  like  the  myeloid  epulis,  having  a  more  rapid  course. 
They  are  far  more  common  in  youth  and  early  life  than  after 
middle  age.  They  show  comparatively  little  disposition  to 
ulcerate,  even  when  injured,  or  when  very  large.  The  most 
interesting  feature  in  their  history  is  their  almost  uniform  be- 
nignancy.  It  is  true,  several  cases  have  been  observed  of  tu- 
mors in  which  myeloid  elements  have  existed,  sometimes  pretty 
largely,  which  have  proved  fatal,  and  many  have  occurred  in 
which  the  myeloid  and  cancerous  elements  have  been  found 
intermingled  in  the  same  tumor.  It  is  also  true,  as  stated  at 
page  280,  that  some  instances  have  been  observed,  in  which  a 
true  metastasis  and  generalization  of  myeloid  disease  have  taken 
place ;  but  the  general  pathological  fact  remains  incontestable, 
that  myeloid  tumors,  as  a  class,  have  usually  none  of  the  charac- 
teristics of  malignancy,  and  that,  when  completely  removed,  we 
may  with  confidence  pronounce  that  they  will  not  return.  A 
partial  or  imperfect  removal  is  certain  to  be  followed  by  a  repro- 
duction of  the  disease,  and  hence  it  becomes  a  study  of  much 
importance  to  ascertain  the  physical  relation  of  these  tumors  to 
the  parts  within  which  or  upon  which  they  grow.  Unfortu- 
nately, it  is  found,  by  careful  examination,  that  these  growths 
have  a  great  propensity  to  push  themselves  in  every  direction,  and 
often,  by  prolongations,  so  slender  as  to  escape  notice,  to  invade 
the  surrounding  areolar  bone-spaces,  or  cavities,  stretching  them- 
selves like  roots,  some  distance  from  the  original  mass.  This  is 
markedly  the  case  with  those  developed  in  the  alveolar  tissue 
of  the  jaws,  where  several  successive  alveoli  have  been  found  to 
contain  small  outgrowths  from  a  tumor,  whose  general  mass  was 
apparently  entirely  independent  of  and  at  some  distance  from 
them.  Again,  small  outlying  tumors  have  been  noticed  imme- 
diately in  the  neighborhood  of  the  principal  mass,  some  so  small 
as  scarcely  to  be  identified,  certain  to  be  overlooked  during  an 


286  TUMORS  OF  BONE. 

operation,  and  only  to  be  found  by  a  careful  anatomical  exami- 
nation. Once  more :  though  these  tumors  have  generally  an 
outline  so  distinct,  and  a  surface  so  lightly  adherent  to  the  sur- 
rounding parts,  that  they  are  in  fact  readily  enucleable,  yet  cer- 
tain ones  are  so  disseminated  through  the  tissue  in  which  they 
form  that  they  might  almost  be  classed  among  the  infiltrations, 
rather  than  as  tumors  properly  so  called,  and  therefore  have  an 
outline  which  cannot  be  accurately  followed  by  the  eye,  much 
less  by  the  knife  of  the  operator.  All  these  are  considerations 
which,  while  they  do  not  aflfect  the  real  benignity  of  the  disease, 
make  it  a  matter  of  prime  importance  that  no  operation  should 
be  undertaken,  or  deemed  satisfactory,  which  does  not  absolutely 
secure  the  entire  ablation  of  the  disease. 

The  development  of  cysts  in  these  tumors  is  a  fact  so  fre- 
quently noticed  as  to  entitle  it  to  belong  to  the  history  of  the 
disease.  This  feature  is  most  prominently  brought  forward 
by  Mr.  Henry  Gray,  in  his  paper  on  "  Myeloid  and  Myelocystic 
Tumors  of  Bone,"  in  the  thirty-ninth  volume  of  the  "  Medico- 
Chirurgical  Transactions ; "  but  Nekton,  and  indeed  all  the 
writers,  acknowledge  their  very  great  frequency.  These  cysts 
are  of  various  forms  and  sizes,  sometimes  as  large  as  a  hen's  egg, 
with  very  distinct,  smooth,  polished  walls,  as  if  lined  by  serous 
membrane ;  often  so  small  as  scarcely  to  be  discerned  by  the 
naked  eye.  Sometimes  they  have  no  clearly-marked  wall,  but 
seem  to  be  mere  cavities,  hollowed  out  in  the  substance  of  the 
tumor,  and  all  conditions  intermediate  between  these  have  been 
seen  in  the  same  growth.  Their  contents  are  usually  reddish 
or  brownish  serum,  sometimes  transparent,  often  muddy,  and 
sometimes  mere  fluid  or  semifluid  blood,  and  this  particularly 
in  those  irregular  and  ill-defined  cavities  which  hardly  ought  to 
be  called  cysts,  and  yet  which  form  a  very  important  feature  of 
the  disease. 

There  seems  to  be  no  very  marked  tendency  in  these  tumors 
toward  ossification,  and  yet  a  certain  amount  of  bone  is  often 
produced  in  the  progress  of  their  growth.  This  bone  is  some- 
times found  in  irregular  plates  of  various  sizes,  but  not  unfre- 
quently  it  pervades  the  mass,  with  some  uniformity,  in  the  shape 
of  a  delicate  framework,  more  or  less  perfect,  giving  a  certain 
feeling  of  firmness  and  solidity  £o  the  tumor  when  lightly  han- 


MYELOID  TUMORS.  287 

died,  but  giving  way  with  a  peculiar  crackling  feel  when  firmer 
pressure  is  made.  The  shell  of  thin  bone,  in  which  these  tu- 
mors are  often  enclosed,  belongs  entirely  to  the  original  bone, 
and  has  no  other  relation  to  the  tumor  than  that  of  enclosing  it. 

As  an  illustration  of  the  history,  both  pathological  and  clini- 
cal, of  these  tumors,  I  know  of  none  more  complete  and  more 
carefully  observed  than  the  following,  which  I  condense  from 
Nelaton's  paper : 

Pierre  Bossuge,  aged  twenty,  came  under  M.  Nelaton's  care 
in  April,  1856.  He  had  noticed,  about  seven  months  previous, 
a  small,  indolent  tumor,  deeply  situated  on  the  face,  just  at  the 
side  of  the  nose.  This  had  gradually  increased,  pressing  upward 
toward  the  orbit,  and  inward  toward  the  nasal  cavity.  At  the 
time  of  admission,  the  tumor  had  gained  the  size  of  a  pigeon's 
egg,  hard  at  its  base,  which  was  evidently  in  the  substance  of 
the  lower  jaw,  and  more  yielding  at  its  more  prominent  sur- 
face. It  had  been  punctured  with  a  lancet  some  time  previous, 
but  only  a  few  drops  of  blood  had  flowed  out.  The  integuments 
and  surrounding  tissues  were  sound,  and  the  man  was  in  a  good 
condition  of  general  health. 

M.  Kelaton  operated  on  the  tumor  on  the  23d.  He  made 
an  incision  into  the  tumor  through  the  mouth,  and  then  broke 
up  and  removed  piecemeal  all  of  the  diseased  mass  which  he 
could  get  away  in  this  manner;  and  then  with  the  hot  iron 
burned  very  thoroughly  in  every  direction  the  cavity  which  he 
had  thus  left.  A  moderate  suppuration  followed,  and  a  gradual 
healing,  so  that  the  cure  appeared  to  be  complete.  On  the  20th 
of  November,  however,  the  man  again  presented  himself  with 
a  reproduction  of  the  tumor,  which  had  now  attained  a  greater 
size  than  before.  It  pressed  far  in  upon  the  nostril,  and  ex- 
tended back  so  as  to  be  felt  in  the  fauces.  The  tumor  also  now 
for  the  first  time  gave  him  some  pain. 

On  the  3d  of  December,  the  whole  superior  maxillary  bone 
was  removed  on  the  left  side,  embracing,  as  was  thought,  every 
portion  of  the  tumor.  The  case  went  on  favorably,  and  he  was 
discharged  cured  early  in  January. 

The  examination  of  the  pieces  removed  in  the  first  opera- 
tion showed  a  reddish,  friable  substance,  much  like  the  sub- 
stance of  the  kidney  or  like  a  lung  in  a  state  of  red  hepatiza- 


288  TUMORS  OF  BONE. 

tion.  M.  Robin  made  the  microscopic  examination,  and  found 
it  almost  entirely  formed  of  myeloplaxes,  with  some  amorphous 
granular  matter,  some  fibro-plastic  cells,  and  a  very 'slight 
fibrous  net-work,  with  a  few  blood-vessels.  The  tumor  exam- 
ined, after  the  removal  of  the  jaw,  was  about  the  size  of  a  large 
hen's  egg.  It  was  situated  in  the  substance  of  the  jaw,  en- 
croaching upon  and  almost  obliterating  the  antrum.  A  section 
displayed  a  firm  elastic  substance,  resembling  the  tissue  of  the 
heart,  or  of  the  foetal  liver,  or  of  a  kidney  in  a  state  of  active 
congestion.  Its  color,  therefore,  was  a  reddish  brown,  pretty 
uniform  in  all  of  its  parts.  In  making  the  section,  the  scalpel 
encountered  some  slender  osseous  fibres  penetrating  the  mass 
in  various  directions.  Several  small  cysts  were  scattered 
through  its  substance,  containing  only  bloody  serum.  The 
microscopical  constitution  of  the  diseased  tissue  was  again 
studied  by  M.  Robin.  He  found  it  "  an  exaggerated  multipli- 
cation of  the  special  elements  of  the  marrow  of  the  bones,  that 
is  to  say,  plates  with  many  nuclei,  i.  e.,  myeloplaxes  bound  to- 
gether by  very  delicate  fibro-plastic  elements,  a  few  laminated 
fibres,  a  certain  amount  of  amorphous  matter,  and  some  capil- 
lary vessels ;  these  last  elements  appeared  in  rather  larger  pro- 
portion than  in  the  first  pieces  examined.  The  vascular  ele- 
ment, however,  plays  evidently  a  very  secondary  part,  for  it  is 
less  developed  than  in  certain  whitish  or  slightly  rose-tinted 
tumors,  considered  as  types  of  encephaloid,  which  were  exam- 
ined by  way  of  comparison."  The  cure  after  this  second  opera- 
tion was  rapid  and  satisfactory.  More  than  three  years  after, 
the  patient  was  seen  and  examined  by  M.  Xelaton,  and  found 
free  from  any  suspicion  of  a  return  of  the  malady. 


CHAPTER  Y. 

PFLSATTNCi  TUMORS   OF   BONE. 


A  DISTINCT  pulsation  is  noticed  in  some  tumors  of  bone, 
the  cause  of  which  is,  in  different  cases,  to  be  traced  to  differ- 
ent pathological  conditions.  Thus  some  of  these  pulsating 
tumors  lie  in  such  relations  to  a  large  artery  that  its  pulsations 


PULSATING  TUMORS   OF  BONE.  289 

are  communicated  to  the  tumor.  In  other  cases  there  is  either 
such  an  abundant  or  such  a  peculiar  vascular  arrangement 
through  the  substance  of  a  tumor,  that  its  own  circulation  gives 
it  an  evident  and  sensible  pulsation.  It  is  clear,  therefore, 
that  the  mere  fact  of  pulsation  existing  in  a  tumor  cannot  give 
it  any  specific  anatomical  character,  or  really  entitle  it  to  be 
considered  as  belonging  to  a  class  of  its  own.  The  symptom  is 
so  striking,  however,  its  discrimination  so  important,  and  its 
bearing  upon  practice  so  direct,  that  most  writers  on  the  subject 
have  given  the  tumors  which  are  characterized  by  it  a  separate 
place  in  their  catalogue.  It  seems  strange  that  so  striking  a 
feature  had  not  earlier  attracted  attention,  but  the  first  distinct 
account  of  a  pulsating  tumor  of  bone  was  one  published  by 
Pearson,  of  London,  in  1790.  Since  attention  has  been  called 
to  it,  numerous  cases  have  been  published,  and  we  are  now  quite 
familiar  with  the  general  facts  which  characterize  these  pulsating 
growths. 

There  are  three  conditions  recognized  as  producing  pulsa- 
tion in  bone-tumors.  These  are :  1.  The  proximity  of  a  large 
artery  which  imparts  its  own  pulsation  to  the  swelling ;  2.  The 
disproportionate  development  and  activity  of  the  vessels  of  the 
tumor  itself;  3.  A  peculiar  arrangement  of  blood-cavities  or 
blood-spaces  in  the  tumor,  which  communicate  with  the  vessels, 
and  which  give  the  structure  a  close  resemblance  to  the  natural 
structure  of  the  corpus  cavernosum  penis. 

Of  the  first  variety,  numerous  instances  are  recorded.  Mr. 
Stanley  gives  the  following :  "  A  man,  aged  sixty-eight,  suffered 
two  severe  foils  upon  the  shoulder.  Subsequently  an  enlarge- 
ment of  the  part  ensued,  with  pulsation  in  it.  The  tumor  was 
considered  to  be  an  aneurism,  and  the  subclavian  artery  was 
tied.  Three  weeks  after  the  operation  the  patient  sank.  The 
tumor  was  found  to  be  a  mass  of  medullary  substance,  to  which 
the  axillary  artery  firmly  adhered,  the  vessel  itself  being  per- 
fectly sound."  Mr.  Stanley  alludes  to  six  other  cases  which 
had  come  to  his  knowledge.  Of  these  six  cases  two  were  in 
the  upper  part  of  the  humerus,  one  in  the  lower  part  of  the 
femur,  one  in  the  head  of  the  tibia,  and  two  in  the  lower  ex- 
tremity of  the  tibia.  In  all  the  disease  had  been  supposed  to 
be  aneurism. 
19 


290  TUMORS  OF  BONE. 

Of  the  second  form,  those  in  which  the  pulsation  is  depend- 
ent upon  unusual  development  of  vessels  in  the  part,  we  have 
perhaps  the  best  examples  in  the  very  vascular  encephaloid  tu- 
mors which  are  sometimes  developed  on  or  in  the  spongy  ex- 
tremities of  the  long  bones.  Other  forms  of  soft  and  rapidly- 
growing  tumors  may  be  accompanied  with  pulsatipn,  but  no 
class  of  tumors  is  so  abundantly  supplied  with  vessels  as  the 
encephaloid,  and  none  so  often  present  this  particular  symptom. 
Indeed,  so  decided  is  this  association,  that  pulsation  in  a  bone- 
tumor  has  come  to  be  looked  upon  with  much  suspicion,  as  being 
extremely  likely  to  depend  upon  the  existence  of  encephaloid 
disease.  Mr.  Paget  remarks :  "  I  think  that,  in  many  of  the' 
cases  which  have  gained  for  erectile  tumors  their  ill  repute,  a 
clearer  examination  would  have  proved  that  they  were,  from 
the  beginning,  very  vascular  medullary  cancers,  or  else  medul- 
lary cancers  in  which  blood-cysts  were  abundantly  formed." 
The  vessels  in  these  cases  are  sometimes  excessive,  merely  in 
number  and  size,  not  in  other  respects  differing  from  the  healthy 
formation ;  while  in  others  they  are  enlarged  irregularly,  tortu- 
ous, varicose,  thinned  in  their  coats,  or  thickened  at  points  ;  in 
short,  they  may  be  in  various  ways  and  degrees  diseased,  as 
well  as  excessively  developed.  The  amount  and  distinctness 
of  the  pulsation  will  of  course  depend  upon  these  anatomical 
conditions  of  the  vessels.  If  they  be  merely  increased  in  num- 
ber and  size,  still  continuing  healthy  in  their  structure,  I  can 
hardly  suppose  that  the  pulsation  can  ever  be  more  than  an  in- 
crease of  the  ordinary  arterial  throbbing,  that  can  be  observed 
in  every  very  vascular  part,  when  it  is  compressed  slightly  by 
the  hand.  If,  on  the  other  hand,  the  vessels  be  very  much 
dilated  in  the  tumor,  over  the  calibre  of  the  parent  trunk  from 
which  its  circulation  is  derived,  and  particularly  if  this  dilatation 
be  irregular  and  pouch-like  at  many  points,  then  we  have,  in 
obedience  to  well-known  hydraulic  laws,  the  conditions  of  a 
pulsation,  which  is  sometimes  so  distinct  and  so  powerful  as 
very  naturally  to  lead  to  the  suspicion  that  our  bone-tumor  is 
an  aneurism — a  mistake  which  has  been  made  in  a  number  of 
instances  by  excellent  and  careful  surgeons. 

The  third  form  of  pulsating  tumor  of  bone,  viz.,  that  in 
which  something  like  a  true,  cavernous,  erectile  tissue  is  formed 


PULSATING  TUMORS   OF  BONE. 


291 


through  the  mass  of  the  growth,  is  much  more  rare.  MM.  Cornil 
and  Ranvier,  in  their  admirable  Manuel  d*  Histologie  Patholo- 
gique,  give  the  following  description  of  this  formation :  "  The  tis- 
sue is  hollowed  out  into  alveoli,  communicating  in  a  very  irregu- 
lar manner  with  each  other,  very  much  in  the  same  way  as  do 
the  alveoli  of  carcinoma.  The  blood  circulates  in  this  cavernous 
system,  which  occupies  the  place  of  the  capillary  system,  situ- 
ated as  it  is  between  the  arteries  and  the  veins.  The  circulation 
through  these  cavities  is  extremely  active."  They  farther  de- 
scribe the  walls  of  the  alveoli  as  composed  of  a  well-marked 
fibrous  tissue,  and  lined  internally  by  a  pavement  epithelium, 
similar  to  that  which  lines  the  veins.  A  curious  fact  is  also 
noted  by  these  observers — that  the  blood  in  these  cavernous 
spaces  contains  very  few  of  the  colorless  blood-globules.  As 
these  are  known,  by  their  adhesiveness  to  the  walls  of  the  ves- 
sels, to  present  a  certain  amount  of  impediment  to  the  natural 
circulation  of  the  blood,  it  is  argued  that  their  comparative  few- 
ness makes  the  circulation  more  active,  and  the  pulsation  there- 
fore more  marked  than  it  would 
be  under  the  ordinary  circum- 
stances of  the  circulation.  The 
reasoning  seems  good,  if  the  facts 
are  accurate ;  and  that  they  are 
so  would  seem  very  probable 
from  the  mode  which  these  gen- 
tlemen adopted  in  their  investi- 
gation. The  mass  after  removal 
was  immediately  placed  in  alco- 
hol, by  which  all  the  blood  in 
the  tumor  was  coagulated.  It 
was  then  cut  into  thin  slices 
and  brushed  over  with  carmine, 
which  adheres  to  the  white  but 
not  to  the  red  globules,  and  then 
soaked  in  glycerine.  This  ren- 
dered it  very  easy  to  count  the 

•'  *  FIG.  78.— (From  Enchsen.) 

number  of  white  globules,  which 

was  done,  with  the  result  above  stated.     Billroth  gives  almost 

precisely  the  same  anatomical  description  of  this  form  of  tumor 


292  TUMORS  OF  BONE. 

as  that  presented  by  the  French  writers  quoted.  Fig.  78,  taken 
from  Erichsen,  is  a  representation  of  what  he  calls  aneurism  by 
anastomosis  of  the  parietal  bone.  It  corresponds  tolerably  well 
with  the  description  of  the  disease  here  given. 

The  clinical  history  of  these  different  forms  of  pulsating  tu- 
mors of  bone,  of  course,  depends  upon  the  nature  of  the  tumor 
itself.  They  are  mostly  found  in  the  extremities  of  the  long 
bones,  the  position  in  which  all  bone-growths  are  most  likely 
to  appear.  The  pulsation  is  sometimes  an  early  and  constant, 
sometimes  a  late,  and  occasionally  an  intermittent  symptom. 
It  may  be  accompanied  with  a  thrill,  sometimes  with  a  distinct 
bruit  de  souffiet,  and  is  sometimes  so  distinctly  and  strongly  ex- 
pansive as  to  puzzle  the  most  careful  and  experienced  examiner. 
The  diagnosis,  however,  can  usually  be  made  from  proper  aneu- 
rism, by  the  location  of  the  tumor,  by  its  evident  connection 
with  and  continuity  with  the  bone  from  which  it  grows,  by  its 
usually  presenting  at  some  period  a  thin  shell  of  bone  on  its 
surface,  and  most  commonly  by  the  feebleness  and  want  of  ex- 
pansiveness  of  the  pulsation. 

The  following  case,  for  which  I  am  indebted  to  my  friend 
Dr.  Charles  D.  Smith,  and  which  I  saw  with  him  on  several 
occasions,  illustrates  extremely  well  some  of  the  usual  clinical 
features  of  the  disease.  I  take  the  account  of  the  case  from  the 
report  published  in  the  New  York  Journal  of  Medicine  for 
March,  1853 : 

"  Miss  C.,  twenty-four  years  of  age,  unmarried,  of  nervous 
temperament,  and  of  previous  good  health,  came  under  my 
care  in  the  month  of  March  last  for  a  painful  swelling  of  the 
left  ankle,  which  came  on  without  any  apparent  cause  a  month 
or  two  before.  The  skin  was  reddened,  and  painful  to  the 
touch,  particularly  over  the  internal  malleolus.  There  was  also 
a  creaking  sensation  about  the  joint  when  handled.  She  walked 
with  difficulty,  increasing  thereby  the  pain  and  tension.  The 
pain  would  occasionally  leave  her,  and  the  swelling  subside. 
It  had  the  complexion  of  a  scrofulous  disease  of  the  joint,  but, 
there  being  no  evidence  of  struma  in  the  system,  I  was  at  a  loss 
to  what  to  attribute  it.  Local  means  as  well  as  constitutional 
remedies  were  resorted  to  without  avail.  The  disease  remained 
about  the  same  until  the  month  of  May,  when  I  detected  some- 


PULSATING  TUMORS  OF  BONE.  293 

thing  like  fluctuation  over  the  internal  malleolus,  which  in  two 
weeks  became  distinct.  The  skin  was  not  changed  in  color, 
neither  did  it  have  the  feel  nor  present  the  appearances  of  an 
abscess. 

"  In  the  early  part  of  June  I  noticed  in  this  situation  a  pul- 
sation which,  from  day  to  day,  became  more  evident,  and  was 
synchronous  with  the  arterial  pulse.  Pressure  on  the  posterior 
tibial  artery  arrested  the  pulsation  in  the  tumor.  At  this  time 
Dr.  Yan  Buren  was  called  in  consultation,  who  confirmed  my 
diagnosis,  viz.,  aneurism  of  the  posterior  tibial  artery,  and  at 
the  same  time  suggested  that  possibly  the  bone  might  be  in- 
volved. She  readily  consented  to  our  proposition,  to  tie  the 
posterior  tibial ;  and,  with  a  view  of  cutting  off  the  recurrent 
circulation,  it  was  also  deemed  advisable  to  pat  a  ligature  upon 
the  anterior  tibial,  where  it  passes  over  the  dorsum  of  the  foot. 
On  the  2d  of  July  the  posterior  tibial  first  was  tied,  about  an 
inch  and  a  half  above  the  tumor.  The  pulsation  ceased  only 
for  a  short  time,  and  the  size  of  the  tumor  was  not  at  all  dimin- 
ished. The  same  result  followed  deligation  of  the  anterior  tibial. 
On  visiting  my  patient  the  morning  following  the  operation, 
the  pulsation  had  returned  with  full  force,  and  was  plainly  felt 
through  the  bandages.  During  the  month  of  July  the  disease 
steadily  increased.  The  skin  in  the  neighborhood  assumed  a 
transparent  appearance.  The  tumor  grew  larger,  more  firm 
and  resisting  to  the  touch,  and  the  pulsation  became  decided. 
Pressure  upon  the  femoral  as  well  as  popliteal  artery  arrested 
it.  Its  true  character  was  determined  by  the  crackling  sensa- 
tion, and  breaking  down  of  something  like  an  osseous  shell,  un- 
der the  fingers.  The  wound  from  the  operation  did  not  heal 
kindly.  It  was  seven  weeks  before  she  recovered,  yet  her  gen- 
eral health  was  not  materially  injured,  either  by  the  progress 
of  the  disease  or  her  long  confinement.  About  the  middle  of 
July  Dr.  Mott  was  called  in  to  decide  the  question  of  amputa- 
tion. His  opinion  was  that,  inasmuch  as  pressure  over  the 
femoral  artery  completely  controlled  the  pulsation  in  the  tu- 
mor, deligation  of  that  artery  might  be  tried.  He  was  also  of 
opinion  that  the  ligature  was  preferable  to  compression  in  this 
particular  case. 

"  On  the  23d  of  August,  Miss  C.,  having  entirely  recovered 


294  TUMORS  OF  BONE. 

from  the  first  operation,  in  the  presence  of  Drs.  Mott,  Van  Bu- 
ren,  Stone,  and  others,  I  placed  a  ligature  around  the  femoral 
artery,  immediately  below  Poupart's  ligament,  and  above  the 
profunda.  Pulsation  in  the  tumor  instantly  eeased,  but  it  did 
not  collapse,  as  in  ordinary  aneurisms,  neither  did  it  dimmish 
in  size.  From  this  operation  my  patient  rapidly  recovered, 
without  any  unpleasant  symptoms.  The  ligature  came  away 
on  the  twenty-second  day,  and  the  wound  healed  readily.  The 
tumor  subsided  about  half  an  inch  in  the  course  of  the  week 
following  the  operation,  but  it  soon  increased  to  its  former 
dimensions. 

"  On  the  12th  of  September  I  felt  a  gentle  pulsation  in  the 
femoral  artery  in  Scarpa's  space,  and  at  the  same  time  in  the 
tumor,  since  which  period  it  has  been  noticed  only  occasion- 
ally, and  then  exceedingly  feeble.  Suffice  it  to  say  the  disease 
steadily  progressed.  The  tibia  expanding,  stretched  the  ante- 
rior tibial  nerve,  causing  great  pain.  Her  health,  too,  began 
to  feel  the  influence  of  the  disease,  and  rendered  amputation 
necessary.  Another  consultation  was  held.  She  was  advised 
to  lose  the  leg,  to  which  she  unhesitatingly  consented,  and  on 
the  20th  of  November  I  removed  it  at  the  place  of  election. 
A  day  or  two  after  its  removal,  my  friend  Dr.  C.  E.  Isaacs  in- 
jected the  limb,  through  the  posterior  tibial  artery,  with  a 
preparation  of  chromate  of  lead  dissolved  in  ether.  The  skin 
and  fascia  were  then  removed,  and  exposed  the  periosteum 
thickened.  The  shell  of  bone  under  it  was  broken  down,  and 
in  some  points  partly  absorbed.  "When  cut  into,  there  was  pre- 
sented a  soft,  brain-like  mass,  of  a  reddish-brown  color,  mixed 
with  the  injecting  material.  Upon  turning  this  out,  it  was  dis- 
covered that  the  lower  end  of  the  tibia  was  absorbed  for  about 
half  an  inch.  The  cartilage  lining  the  surface  articulating  with 
the  astragalus  was  preserved.  The  bone  was  expanded  into  a 
thin  shell,  the  cancellated  structure  gone,  and  its  place  occupied 
by  the  matter  described.  No  vessels  were  found  entering  the 
tumor,  although  the  bone  and  neighboring  parts  were  exceed- 
ingly vascular.  The  other  tissues  were  healthy." 

Another  case  was  under  the  care  of  my  friend  and  colleague, 
Dr.  "Willard  Parker,  about  the  same  time,  and  was  published  in 
the  same  journal  in  the  number  for  May,  1853.  It  gives  so 


PULSATING  TUMORS  OF  BONE.  295 

many  features  of  interest  in  the  history  and  progress  of  the  dis- 
ease that  I  give  it  almost  entire,  as  related  by  the  patient  him- 
self, who  was  an  intelligent  physician : 

"  In  the  summer  of  1842,  while  jumping  for  recreation,  I 
struck  my  left  heel  upon  a  round  stick  about  an  inch  in  diame- 
ter ;  it  gave  me  severe  pain  at  the  time,  which,  however,  lasted 
but  a  few  minutes,  and  I  thought  no  more  of  it.  Several  days 
after,  upon  rising  from  my  bed  in  the  morning,  I  experienced 
a  sharp  pain  darting  through  my  heel,  which  quickly  passed  off, 
but  recurred  again  on  the  following  morning  in  the  same  man- 
ner. This  transient  pain  continued  to  return  every  morning  on 
assuming  the  erect  position,  until  the  summer  of  1847,  without 
the  occurrence  of  any  other  symptom,  such  as  swelling  or  ten- 
derness, to  indicate  the  nature  or  seat  of  the  difficulty.  This 
pain  invariably  returned  on  rising  to  my  feet,  after  resting  some 
time  in  the  horizontal  position,  but  never  continued  to  exceed 
one  or  two  minutes.  During  this  period,  my  heel  gave  me  no 
uneasiness,  my  general  health  was  good,  with  the  exception  of 
some  dyspeptic  symptoms  for  two  or  three  years  after  the  in- 
jury, which  I  attributed  to  sedentary  habits,  being  then  a  stu- 
dent, and  which  passed  off  after  engaging  in  practice. 

"In  the  summer  of  1847  I  began,  for  the  first  time,  to  ex- 
perience a  tenderness  about  the  heel  whenever  it  came  in  con- 
tact with  solid  substances  with  more  than  ordinary  force,  as  in 
stamping  or  making  a  false  step.  This  tenderness  gradually 
increased,  until  I  began  to  suifer  some  pain  in  walking  at  my 
usual  pace,  unless  I  was  careful  to  slide  my  foot  along  without 
raising  it  much  from  the  ground.  There  was  no  appreciable 
swelling  until  December  of  that  year,  when,  upon  drawing  on 
my  boot  one  morning,  I  suffered  so  much  pain  that  I  was  obliged 
to  withdraw  it  immediately.  During  the  day  the  heel  swelled 
considerably,  and,  being  hot  and  painful  at  night,  I  scarified  it 
deeply,  and  held  it  in  hot  water  to  favor  the  bleeding.  On  the 
following  day  I  was  disappointed  at  finding  my  foot  still  worse, 
and  was  obliged  to  use  a  crutch  in  walking.  Leeches  and  poul- 
tices were  applied,  and  subsequently  iodine  and  other  medicinal 
applications  were  employed,  but  without  even  palliating  the 
symptoms.  Nothing  but  cold  water  and  snow  gave  me  even 
temporary  relief ;  these  were  very  grateful,  and  I  resorted  to 


296  TUMORS  OF  BONE. 

them  often,  as  the  relief  they  afforded  enabled  me  to  attend  to 
my  business,  though  I  suffered  much  pain  night  and  day. 

"  I  continued  to  grow  gradually  worse  until  some  time  in 
February,  1848,  when  I  determined  to  consult  Dr.  Parker.  At 
this  time  there  seemed  to  be  thickening  of  all  the  tissues  about 
the  os  calcis,  with  a  deep-seated,  constant  pain,  as  if  the  fibrous 
tissue  was  put  upon  the  stretch  ;  occasionally  the  pain,  was  lan- 
cinating. 

"  Dr.  Parker  advised  an  incision  down  to  the  bone,  which 
he  accordingly  made,  dividing  the  periosteum  of  the  os  calcis 
about  an  inch  and  a  half  on  its  inferior  surface ;  the  wound 
bled  freely,  and  gave  a  little  relief  to  the  severity  of  the  pain, 
but  of  short  duration.  I  kept  the  wound  discharging  four  or 
five  weeks,  but,  finding  no  material  benefit,  allowed  it  to  heal. 
Soon  after  this  I  applied  moxas,  by  the  advice  of  Dr.  Ticknor, 
TJ.  S.  Navy,  but  with  no  benefit.  The  pain  continued  to  in- 
crease in  severity,  being  worse  at  night  than  during  the  day. 
I  resorted  to  large  doses  of  morphine  to  obtain  sleep,  and  often 
two  grains  at  a  dose  would  produce  only  a  short  nap,  from 
which  I  would  be  awakened  by  the  most  excruciating  lanci- 
nating pains  in  the  heel.  I  finally  began  the  use  of  quinine  in 
the  summer  of  1848,  as  I  was  beginning  to  emaciate  and  to 
lose  my  appetite,  taking  eight  grains  a  day,  with  cold  applica- 
tions to  the  affected  part.  Under  this  treatment  my  appetite 
and  general  health  improved,  and  also  the  local  difficulty  ;  the 
pain  was  much  less  severe,  and  in  a  short  time  I  threw  aside 
my  crutch,  still  continuing  my  practice,  and  got  around  very 
comfortably  with  a  cane.  This  improvement  lasted  until  De- 
cember, 1848,  when  I  had  an  attack  of  acute  bronchitis,  for 
which  I  was  bled,  and  took  antimony,  and  of  course  omitted 
the  quinine.  I  was  confined  to  my  bed  about  ten  days,  and  in 
this  time  the  pain  in  my  heel  became  worse.  On  getting  up 
I  discovered,  for  the  first  time,  a  tumor  on  the  outer  aspect  of 
the  heel,  just  below  the  external  malleolus,  which  had  a  spongy, 
elastic,  and  pulsating  feel,  and  was  painful  on  pressure ;  the 
veins  were  much  enlarged  about  the  heel.  I  again  resorted  to 
the  quinine,  from  which  I  had  derived  so  much  benefit,  but  it 
now  gave  me  no  relief. 

"  I  grew  worse  so  rapidly  that  I  again  visited  New  York  with 


PULSATING  TUMORS  OF  BONE.  297 

the  intention  of  submitting  to  amputation,  if  this  course  was 
deemed  advisable.  I  had  come  to  the  conclusion  that  I  could 
not  much  longer  survive  such  indescribable  agony  (I  will  not 
call  it  by  so  soft  a  name  as  pain).  Dr.  Parker  advised  imme- 
diate amputation,  to  which  I  cheerfully  assented.  lie  per- 
formed the  operation  on  the  24th  of  January,  1849,  after  ad- 
ministering a  mixture  of  chloroform  and  ether.  I  resumed  the 
practice  of  my  profession  about  three  months  after  the  opera- 
tion, and  have  continued  actively  engaged  since,  in  the  enjoy- 
ment of  good  health.  I  have  supplied  my  deficient  extremity 
with  an  artificial  limb,  which  answers  its  purpose  admirably." 

On  examination,  it  was  found  "  the  bone  expanded  into  a 
thin  shell,  the  cancellated  structure  absorbed,  and  in  its  place 
a  material  answering  the  character  of  carcinoma." 

Both  these  cases  seem  to  have  been  instances  of  the  softer 
variety  either  of  cartilaginous  or  myeloid  or  possibly  of  the 
spindle-celled  growth,  which,  from  the  excessive  development 
of  their  vessels,  received  the  pulsating  character.  Their  gen- 
eral appearance  was  that  of  encephaloid  disease,  but  that  they 
were  not  truly  cancerous  affections  is  proved  by  their  after-his- 
tory. The  last  case,  the  tumor  of  the  heel,  was  alive  and  well 
four  years  after  the  amputation,  and  Dr.  Smith  has  recently  in- 
formed me  that  his  patient  was  entirely  free  from  any  symptom 
of  recurrence  of  her  malady  two  years  ago,  being  about  sixteen 
years  after  her  limb  was  removed. 

Practically  speaking,  the  main  interest  which  attaches  to 
these  tumors  is  the  question  of  treatment.  The  pulsation,  par- 
ticularly where  it  is  well  marked,  very  naturally  suggests  itself 
as  a  prime  factor  in  the  problem,  and  the  question  of  cutting 
off  the  circulation  by  ligature  almost  necessarily  presents  itself 
to  the  mind.  It  has  been  put  to  the  test  of  experiment  in  quite 
a  number  of  instances.  Dr.  Smith,  in  the  paper  above  quoted, 
refers  to  Dupuytren  as  the  first  surgeon  who  tried  the  ligature. 
"  His  case  occurred  just  below  the  knee,  at  the  inner  side  of  the 
tibia,  in  a  man  aged  thirty-two.  He  tied  the  femoral,  the  pul- 
sation ceased,  and  the  tumor  disappeared.  Seven  years  after, 
it  returned  and  acquired  a  large  size ;  he  amputated,  and  the 
patient  recovered.  It  proved  to  be  composed  of  numerous 
cysts,  some  filled  with  gelatinous  matter,  and  others  with  co- 


298  TUMORS  OF  BONE. 

agulated  blood.  A  fine  membrane  lined  these  cysts,  through 
which  vessels  were  seen  distributed  in  the  form  of  a  close  net- 
work." This  seems  to  be  the  most  satisfactory  result  that  has 
been  attained.  Lallemand,  Roux,  Yelpeau,  Guthrie,  Luke, 
Hargreaves,  and  Teale,  have  each  operated  by  ligature,  with  a 
partial  or  negative  result ;  in  the  best  cases  the  growth  of  the 
tumor  being  arrested  only  for  a  few  weeks  or  months,  the  dis- 
ease then  resuming  its  original  rate  of  progress,  until  death  or 
amputation  relieved  the  patient  of  his  sufferings. 

A  certain  and  sometimes  very  great  mitigation  of  pain  is  oc- 
casionally gained  by  cutting  off  the  circulation  in  these  tumors, 
evidently  by  relieving  the  tension  of  the  growing  mass  on  the 
unyielding  tissues  by  which  it  is  imprisoned.  This  I  have  expe- 
rienced in  two  cases  of  malignant  disease  of  superior  maxillary 
bone,  where  the  disease  had  extended  so  far  as  to  preclude  any 
idea  of  extirpation.  In  one  of  these  cases  I  applied  a  ligature 
to  the  common  carotid,  in  hope  of  arresting  the  progress  of  the 
malady.  The  patient  died  a  few  days  after  the  operation,  too 
soon  to  judge  of  any  effect  on  the  growth  of  the  mass,  but  not 
too  soon  to  demonstrate  that  the  operation  had  brought  imme- 
diate and  complete  relief  to  the  excessive  pain  which  he  had 
been  suffering.  In  the  other  case,  for  a  similar  but  more  des- 
perate condition  of  the  superior  maxillary,  malar,  and  temporal 
bones,  in  the  hope  of  alleviating  dreadful  and  constant  pain, 
and  perhaps  arresting  somewhat  the  progress  of  the  growth,  I 
tied  the  common  and  internal  carotids ;  the  former  half  an 
inch  below,  and  the  latter  half  an  inch  above,  the  bifurcation. 
I  did  this  with  a  view  of  more  completely  controlling  the  re- 
current circulation  through  the  common  carotid  from  the  other 
side,  which  so  quickly  reestablishes  itself  through  the  circle  of 
"Willis.  The  man,  who  was  old  and  feeble,  died  about  a  week 
after  the  operation,  but  during  that  time  was  entirely  freed 
from  pain,  so  as  not  even  to  require  an  anodyne  to  procure 
sleep  at  night.  In  1854,  Dr.  John  Neill,  of  Philadelphia,  tied 
both  occipitals  for  the  cure  of  a  large  pulsating  tumor  of  the 
occipital  bone.  It  had  been  growing  slowly  for  many  years, 
but  more  recently  its  increase  had  been  more  rapid.  "  It  had 
a  pulsation  distinctly  perceptible  both  to  the  eye  and  touch,  ac- 
companied by  a  marked  aneurismal  bruit.  The  pulsation  was 


PULSATING  TUMORS  OF  BONE.  299 

not  a  simple  rising  and  falling  of  the  tumor,  but  an  expansion 
in  all  directions.  The  right  occipital  artery  could  be  felt  beat- 
ing strongly,  and  with  a  distinct  thrill.  Pressure  upon  it  sen- 
sibly diminished  the  pulsation  of  the  tumor,  and  pressure  upon 
both  occipitals  almost  entirely  destroyed  pulsation."  The  effect 
of  the  ligature  of  these  arteries  was  to  check  in  some  degree 
the  progress  of  the  disease.  The  patient  lived  four  or  five 
months  after  the  operation,  no  change  taking  place  in  the  tu- 
mor, except  a  diminution  of  pulsation  and  bruit.  Post-mortem 
examination  showed  the  tumor  to  be  of  an  encephaloid  nature, 
and  encroaching  largely  on  the  cerebral  cavity. 

Dr.  E.  D.  Mapother  reported  to  the  Surgical  Society  of 
Ireland,  January  23,  1863,  a  case  of  pulsating  tumor  on  the 
left  tibia,  in  which,  after  trying  a  variety  of  remedies,  he 
finally  determined  to  use  the  actual  cautery.  There  did  not 
seem  to  be  much  encouragement  to  attempt  the  ligature,  as  he 
found  that  pressure  upon  the  femoral  did  not  control  the  pulsa- 
tion. He  says,  in  his  report  in  the  Dublin  Free  Press,  Febru- 
ary 4,  1863:  "We  resolved  to  try  the  effect  of  actual  cautery, 
and  having  chloroformized  the  patient,  we  pressed  an  iron  but- 
ton of  the  diameter  of  a  shilling,  heated  to  a  white  heat,  deep 
into  the  tumor ;  a  good  deal  of  haemorrhage  followed,  but  was 
repressed  by  muriated  tincture  of  iron.  In  seven  days  the  slough 
separated  in  small  gritty  pieces,  and  then  was  disclosed  a  mass 
of  hard,  pulsating  substance,  of  the  shape  of  large  granulations, 
but  of  a  pale  color.  Seeing  that  it  was  necessary  to  reapply 
the  cautery,  we  did  it  this  time  with  a  sharp  conical  iron,  which 
was  thrust  five  times  into  the  tumor,  and  thus  it  burnt  its  way 
for  an  inch  and  a  half  from  the  surface  of  the  tibia.  In  ten 
days  a  thick  and  somewhat  conical  slough  came  away,  leaving  a 
cavity  filled  with  small,  healthy  granulations  at  its  sides,  but 
with  a  small  spot  of  rough  bone  at  the  bottom.  This  gradually 
became  covered  in,  and  the  ulcer  assumed  the  healthiest  charac- 
ter." At  the  end  of  two  months,  Dr.  Mapother  reports  the 
ulcers  healed,  and  the  tumor  entirely  removed.  At  the  end  of 
a  year  the  patient  was  still  perfectly  well. 

Of  course,  if  the  tumor  be  favorably  situated,  there  may  be 
cases  in  which  extirpation  can  be  performed  by  the  gouge  and 
saw.  Here  the  result  will  depend  on  the  nature  of  the  tumor ; 


300  TUMORS  OF  BONE. 

but,  as  far  as  I  know,  the  mere  fact  of  the  vascular  character  of 
the  tumor  need  not  discourage  the  resort  to  the  usual  opera- 
tions in  similar  non-pulsating  growths.  In  the  limbs,  amputa- 
tion has  been,  in  by  far  the  larger  number  of  cases,  the  only 
method  of  ridding  the  patient  of  his  alarming  and  very  com- 
monly fatal  disease. 


CHAPTER  VI. 

TUMORS    OF    THE    JAWS. 

THE  enlargements  and  tumors  which  we  encounter  on  the 
jawbones  present  so  many  features  which  are  peculiar  to  the 
bones  in  which  they  occur,  that  it  is  convenient,  in  studying 
these  affections,  to  place  them  under  one  head,  and  thus  bring 
together  many  points  which  are,  in  other  parts  of  the  skeleton, 
differently  classified.  This  arises  partly  from  the  anatomical 
peculiarities  of  the  jaws,  such  as  the  large  mucous  cavity  of  the 
antrum,  the  spongy  substance  of  the  alveoli,  the  implantation 
of  the  teeth,  the  close  connection  of  the  gingival  membrane 
with  the  bone,  the  large  proportion  of  the  bone  which  is  cov- 
ered by  mucous  membrane ;  and  partly  certain  pathological  pe- 
culiarities, such  as  the  fact  that  cystic  disease  of  bone  is  almost* 
exclusively  found  in  this  region,  and  that  the  myeloid  tumor  is 
so  habitually  found  in  these  bones,  rather  than  in  the  other 
bones  of  the  skeleton,  that  its  whole  history  might  be  written 
from  its  development  in  this  part  alone.  Besides,  the  very  su- 
perficial position  of  both  upper  and  lower  jaws  makes  some 
important  modification  in  the  facility  and  completeness  of  the 
diagnosis  of  their  diseases,  while  their  accessibility  gives  pe- 
culiar advantages  to  the  surgeon  in  seeking  their  cure  or  extir- 
pation. Most  of  the  writers  on  diseases  of  the  bones  have 
found  it  convenient,  for  these  reasons,  to  discuss  the  affections 
of  the  jaws  under  a  division  by  themselves.  I  shall  follow  so 
good  an  example,  and  present  what  I  have  to  say  on  this  divis- 
ion of  the  subject  under  the  following  heads ; 


TUMORS  OF  THE  JAWS.  301 

1.  Inflammatory  distention  of  antrum. 

2.  Cysts  and  cystic  growths  in  the  jaws. 

3.  Tumors  connected  with  the  gums. 

4.  Solid  tumors  of  the  jawbones. 

INFLAMMATORY   DISTENTION   OF  ANTRUM. 

Inflammation,  attacking  the  mucous  membrane  lining  the 
antrum,  may,  by  retention  of  the  inflammatory  products,  from 
a  closure  of  the  small  opening  into  the  nostril,  cause  a  disten- 
tion of  the  cavity,  which  even  in  acute  cases  may  reach  a  con- 
siderable size,  and  in  the  chronic  form  may  give  rise  to  doubts 
and  mistakes  as  to  the  nature  of  the  swelling  which  is  thus 
produced.  Inflammation  of  this  cavity  may  be  an  extension  of 
catarrhal  disease  from  the  nasal  cavity,  or  it  may  originate  from 
some  diseased  condition  of  the  roots  of  the  first  and  second 
molar  teeth  which  project  upon  its  floor,  sometimes  slightly, 
and  sometimes  quite  considerably.  External  injury,  particularly 
that  of  extraction  of  the  molar  tooth,  is  a  frequent  cause  of  this 
affection.  The  symptoms  can  usually  be  easily  recognized  by 
the  dull,  aching  pain  localized  in  the  centre  of  the  upper  jaw, 
and,  after  a  very  short  time,  the  general  inflammatory  swelling 
of  the  face  is  seen  to  be  connected  with  an  enlargement  of  the 
jawbone  itself,  which,  in  the  region  of  the  antrum,  is  extreme- 
ly sensitive  to  the  touch.  As  the  distention  increases,  the  suf- 
ferings of  the  patient  become  more  severe,  and  the  deformity 
of  the  face  more  and  more  marked.  The  bony  wall  of  the  an- 
trum, as  it  yields  to  the  accumulating  fluids  within,  becomes 
thinned,  and  gives  the  yielding,  crackling,  broken  egg-shell  sen- 
sation, so  characteristic  of  distended  bone.  If  the  attack  be 
very  acute,  the  matter  finds  its  way  pretty  early  through  the 
nostril,  or  under  the  cheek  anteriorly,  or  through  the  floor  of 
the  antrum,  into  the  mouth.  If  a  tooth  has  been  recently  ex- 
tracted, its  socket  often  affords  a  ready  outlet  for  the  matter, 
and  suggests  the  most  direct  mode  of  reaching  it  with  the  sur- 
geon's trocar. 

If,  however,  as  is  perhaps  more  commonly  the  case,  the 
acute  symptoms  abate,  and  a  subacute  or  chronic  course  is  as- 
sumed by  the  disease,  then  the  external  evidences  of  inflamma- 
tion gradually  subside,  while  the  disteution  of  the  antrum  as 


302  TUMORS  OF  BONE. 

gradually  increases,  and  the  affection  often  presents  itself  in 
a  shape  that  leaves  it  very  doubtful  whether  the  tumor  is  one 
depending  upon  accumulation  of  pus,  or  whether  it  be  a  cystic 
growth  in  the  antrum.  Indeed,  it  is  recorded  that  surgeons 
have  undertaken  the  removal  of  the  upper  jaw,  under  such  cir- 
cumstances, and  have  not  discovered  their  mistake  until  their 
hands  have  been  covered  with  pus  from  the  ruptured  abscess. 
Liston  and  Stanley  both  mention  such  occurrences ;  and  the 
facility  with  which  even  a  good  surgeon  might  fall  into  such  an 
error  will  perhaps  be  appreciated,  when  we  remember  that,  in 
many  of  these  cases,  the  early  history  of  inflammation  has  been 
unnoticed  or  forgotten,  and  that,  in  those  instances  where  the 
actions  are  very  slow  and  deliberate,  a  thickening  and  indura- 
tion of  the  distending  wall  of  the  antrum  take  place,  instead 
of  a  thinning  of  it,  which  thickening  conceals  the  fact  of  the 
existence  of  a  fluid  within,  and  thereby  makes  the  diagnosis 
sometimes  extremely  difficult. 

The  consequences  of  these  inflammatory  distentions  of  the 
antrum  are  often  serious.  Necrosis  of  the  bone  is  sometimes 
produced,  as  in  a  case  related  by  Mr.  Christopher  Heath,  where 
"  the  front  part  of  the  floor  of  the  orbit,  the  upper  cheek-portion 
of  the  superior  maxilla,  and  the  infra-orbital,  and  a  large  plate  of 
bone  from  the  inner  (nasal)  wall  of  the  antrum,"  were  involved 
and  removed  as  sequestra.  In  this  case,  the  eyeball  had  been  en- 
croached upon  by  the  swelling,  and,  from  the  pressure,  the  sight 
had  been  utterly  destroyed.  Other  instances  are  recorded 
where  amaurosis  followed  this  disease,  and  one  in  which  con- 
vulsions and  death  in  sixteen  days  were  produced  by  it.  At 
all  times  it  is,  in  its  acute  form,  a  painful  and  deforming  dis- 
ease, in  which  the  assistance  of  art  should  be  invoked  as  soon  as 
possible.  An  opening  may  be  made  into  the  antrum  in  one  of 
two  ways :  Either  the  socket  of  the  first  molar  tooth  may  be 
perforated  by  a  trocar,  or  the  lower  part  of  the  anterior  wall 
of  the  antrum,  just  above  the  gum,  may  easily  be  penetrated, 
and  a  portion  of  the  thin  shell  removed  sufficient  to  allow  a 
free  and  permanent  opening  into  the  antral  cavity.  If  the 
molar  tooth  be  sound,  the  second  will  probably  be  the  best 
method.  Of  course,  after  such  an  inflammation,  the  cavity 
does  not  immediately  return  to  a  healthy  condition,  its  mucous 


TUMORS  OF  THE  JAWS.  303 

membrane  continuing  for  an  indefinite  time  to  secrete  muco-pus, 
which,  if  the  opening,  made  by  the  surgeon,  be  not  kept  free, 
will  accumulate  and  give  rise  to  a  return  of  pain,  and  perhaps 
a  renewal  of  the  inflammatory  disease.  The  opening  through 
the  bone,  in  whichever  situation  it  is  made,  should  be  free,  and 
it  will,  in  most  cases,  be  necessary  to  dilate  it  at  stated  inter- 
vals, to  prevent  its  contraction.  In  doing  this,  I  prefer  a  coni- 
cal steel  bougie,  introduced  and  allowed  to  remain  a  few  min- 
utes, at  appropriate  intervals,  as  giving  less  pain  and  being  less 
liable  to  do  mischief  than  the  sponge-tent.  The  cavity  should 
also  be  frequently  injected  with  warm  water  or  some  slightly 
stimulating  or  corrective  lotion,  such  as  sulphate  of  zinc,  car- 
bolic acid,  or  chloride  of  soda,  or,  what  I  like  better  than  all,  a 
weak  solution  of  common  salt.  I  have  under  my  care  a  gen- 
tleman, aged  thirty-six,  who  noticed  about  six  years  ago  a  pain- 
less swelling,  just  above  the  root  of  the  right  first  molar  tooth. 
It  gradually  grew  larger  and  larger,  and  soon  began  to  make  a 
decided  prominence  of  the  cheek.  It  was  then  it  came  under 
my  notice.  I  found  the  anterior  wall  of  the  antrum  bulged 
forward  into  a  prominent  tumor,  which  was  covered  by  the 
thinned  bone,  and  crackled  under  the  finger,  giving  a  distinct 
feeling  of  fluctuation.  The  swelling  was  now  somewhat  tender 
and  painful,  and  was  gradually  becoming  more  so.  I  recom- 
mended that  the  first  molar,  which  he  suspected  was  the  cause 
of  the  trouble,  should  be  removed,  and  as  it  was  drawn  from 
its  socket,  matter  flowed  freely,  and  the  tumor  partly  collapsed. 
This  was  about  two  years  from  the  time  when  he  first  noticed 
the  swelling.  Since  the  opening,  the  cavity  has  been  kept  free 
by  injections  of  water  or  salt  and  water,  or  a  solution  of  sul- 
phate of  zinc.  Occasionally  I  have  introduced  a  probe,  or  a 
conical  bougie.  If  this  is  neglected,  and  accumulation  is  al- 
lowed, he  immediately  begins  to  suffer  pain,  and  the  whole  jaw 
feels  inflamed.  By  constant  care  of  this  kind,  the  antral  cavity 
has  now  shrunk  so  as  to  contain  much  less  injected  fluid  than  it 
formerly  did;  it  discharges  but  little,  the  prominence  is  no 
longer  visible  ;  in  short,  it  is  gradually  and  very  slowly  regain- 
ing a  healthy,  natural  condition. 

Some  remarkable  cases  of  extreme  distention  are  on  record 
from  the  accumulation  of  fluids  within  the  antrum.     A  very 


304 


TUMORS   OF  BONE. 


striking  case  is  spoken  of  by  Mr.  Heath  as  having  occurred  to 
Sir  William  Fergusson,  the  preparation  from  which  is  preserved 
in  the  King's  College  Museum:  "It  was  taken,  many  years 
ago,  from  a  subject  in  the  dissecting-room,  and  from  the  person 
of  an  old  woman.  The  tumor,  which  was  of  very  large  size, 
had  burst  shortly  before  death,  leaving  the  remarkable  deform- 
ity, shown  in  Fig.  79,  which  is  due  to  the  complete  absorption 
of  the  front  wall  of  the  antrum,  and  its  collapse,  by  which  a 
prominent  horizontal  ridge  of  bone,  formed  by  the  upper  wall 
of  the  antrum,  has  been  left  immediately  below  the  orbit.  The 
preparation  shows  great  distention  of  the  antrum,  the  diameter 

of  which  varies  in  different  parts 
from  two  to  two  and  a  half 
inches,  and  bony  wall  so  thinned 
out  as  to  resemble  parchment. 
The  gums  are  edentulous.  There 
is  no  communication  between 
the  nose  or  mouth  and  the  cavi- 
ty, which  is  lined  by  a  membrane 
covered  with  laminated  deposit. 
Whether  this  was  originally  a 
case  of  cystic  growth  or  a  chronic 
abscess,  it  is  impossible  now  to 
decide  ;  but  it  is,  so  far  as  I  am 
aware,  a  unique  post-mortem 
specimen  of  this  distention." 

Besides    this    Case    of    simple 

distention  of  the-  antrum  by  the 
accumulation  of  fluids  within  it,  there  are  other  cases  in  which 
a  true  cystic  formation  occurs  within  this  cavity.  Sometimes  a 
single  cyst  is  found  growing  in  the  antrum,  to  some  part  of 
whose  mucous  membrane  it  is  attached.  These  have  been  de- 
tected in  all  stages  of  their  growth,  from  the  smallest  noticeable 
size  up  to  the  point  of  completely  filling  and  distending  the 
antrum.  Their  walls  are  usually  thin,  and  their  contents  are 
described  as  most  commonly  of  a  transparent  viscid  character, 
but  in  the  older  tumors  becoming  flaky  from  the  presence  of 
cholesterine,  and  occasionally  thick  and  opaque  like  butter  or  the 
caseous  fluid  found  in  sebaceous  cysts.  Sometimes,  instead  of 


FIG.  79.-(From  Heath.) 


TUMORS  OF  THE  JAWS.  305 

being  single,  there  are  several  cysts,  and  Mr.  Heath  gives  one 
instance,  taken  from  M.  Giraldes's  prize  essay  on  this  subject, 
where  the  whole  of  both.antra  were  packed  full  of  cysts  of 
varying  size,  but  of  great  numbers,  and  in  every  stage  of  devel- 
opment. These  cases,  of  course,  during  life,  present  no  features 
by  which  they  can  be  distinguished  from  the  other  forms  of 
chronic  antral  distention.  As  to  their  management,  particu- 
larly where  many  of  them  exist,  it  is  evident  that  an  operation, 
more  thorough  and  more  extensive  than  mere  puncture,  would 
be  necessary  for  their  perfect  removal. 


CYSTS   AND   CYSTIC   GROWTHS   Df   THE  JAWS. 

Cysts  may  occur  in  the  substance  of  either  jawbone,  and 
present  themselves  sometimes  in  connection  with  the  teeth,  and 
sometimes  entirely  independent  of  them.  Of  those  connected 
with  the  teeth,  some  are  attached  to  the  fangs  of  perfectly  de- 
veloped teeth,  and  others  are  found  to  be  connected  with  teeth 
either  imperfectly  developed  or  abnormally  placed  in  the  jaw, 
which  wrongly-developed  teeth  are  commonly  considered  to  be 
the  cause  of  the  formation  of  the  cystic  tumor,  by  reason  of  the 
local  irritation  which  they  produce. 

Of  cysts  connected  with  the  roots  of  sound  and  well-devel- 
oped teeth,  Mr.  Heath  gives  three  examples  as  coming  under 
his  observation.  They  are  stated  to  be  quite  small,  and,  judging 
from  the  drawings,  not  larger  than  a  pea,  except  one  of  them, 
which  is  the  size  of  a  hazel-nut.  One  of  them  has  quite  a  long 
pedicle  by  which  it  is  attached  to  the  end  of  the  fang.  They 
may,  however,  grow  to  a  large  size,  and  several  cases  are  on 
record  where  they  have  intruded  into  the  antrum,  which  cavity 
they  have  more  or  less  completely  occupied.  Of  course,  the 
discrimination  between  such  a  case  and  one  originating  in  the 
antrum  could  hardly  be  made,  except  by  a  careful  dissection  of 
the  parts  after  death  or  removal. 

Of  cysts  connected  with  undeveloped  or  misplaced  teeth, 
dentigerous  cysts,  examples  have  now  been  recorded  by  many 
observers.  Most  commonly  it  is  the  permanent  teeth  which,  by 
their  abnormal  condition,  give  rise  to  the  cystic  growth,  but  it 
has  been  occasionally  found  in  connection  with  the  temporary 
20 


306  TUMORS   OF  BONE. 

teeth,  and,  in  at  least  one  instance,  with  a  supernumerary  tooth. 
The  explanation  of  the  mode  in  which  these  cysts  are  formed 
about  the  impacted  tooth  is  given  by  Mr.  Salter  as  follows: 
"  When  a  tooth  is  thus  situated,  its  fang  is  enclosed  in  a  bony 
socket,  lined  by  periosteum,  as  in  ordinary  circumstances,  while 
the  crown  of  the  tooth  is  free  in  a  little  bony  loculus,  lined  by 
that  which  was  the  so-called  '  enamel-pulp.'  This  structure  is 
clothed  with  a  sort  of  epithelium,  which  is  apt  to  assume  the 
function  of  secreting  fluid.  After  the  enamel  is  completely 
formed,  the  soft  membrane,  which  rests  upon  the  surface  of  the 
crown  of  the  tooth,  frequently  separates  from  it,  the  interval 
being  occupied  by  a  sort  of  serum.  This  is  generally  the  result 
of  some  irritation  or  difficulty  in  tooth-cutting ;  and  where  the 
irritation  runs  on  to  acute  inflammation,  as  in  some  cases  of 
tedious  eruption  of  wisdom-teeth,  the  secretion  may  become 
purulent.  In  the  deep-seated  cases  of  impaction  of  teeth,  the 
action^,  I  believe,  always  slow,  and  the  secretion  almost  always 
serous." 

Mr.  Salter  gives  two  instances  of  his  own,  one  of  which  I 
will  relate,  as  a  type  of  this  class  of  cases:  "A  girl,  eighteen 
years  of  age,  had  an  elastic  fluid-containing  tumor  in  the  sub- 
stance of  the  incisive  bone,  extending  up  to  the  base  of  the 
nose  on  the  left  side.  She  had  been  seen  by  two  or  three  sur- 
geons, but  the  nature  of  the  malady  was  not  ascertained.  She 
had  the  normal  number  of  teeth  in  the  jaw,  though  the  char- 
acter of  one  of  them  was  abnormal  for  her  age.  When  the 
patient  was  sent  to  me  for  my  opinion,  I  perceived  that  the  left 
central  incisor  was  a  temporary  tooth ;  and  this  circumstance 
was  a  key  to  the  correct  diagnosis  of  the  case.  The  left  tem- 
porary central  incisor  occupied  a  position  which  its  permanent 
successor  should  have  held;  the  absence  of  the  tooth,  under 
such  circumstances,  suggested  the  almost  inevitable  position 
which  it  must  occupy  above  and  behind  its  temporary  prede- 
cessor, that  is,  in  the  axis  of  the  serous  cyst.  The  temporary 
tooth  was  removed,  and  the  cyst  explored,  to  discover  the  suc- 
ceeding tooth.  The  permanent  central  incisor  was  found  deep 
in  the  bone,  in  an  upright  and  natural  direction ;  its  crown  bare 
within  the  cyst ;  but,  upon  its  removal,  it  was  observed  that 
the  fang  was  aborted,  and  had  only  grown  to  one-fifth  of  its 


TUMORS  OF  THE  JAWS.  307 

natural  length.  This  circumstance  it  was  which  had  prevented 
its  extruding  its  temporary  predecessor,  and  establishing  itself 
in  its  normal  position.  The  retention  of  the  tooth  in  its 
epithelioid  sac  furnished  the  anatomical  grounds  from  which, 
under  favoring  circumstances  of  irritation,  the  serous  secretion 
arose,  and  the  bone-expansion  followed." 

Fig.  80,  taken  from  Mr.  Heath's  work,  represents  a  lower 
jaw  distended  by  a  cystic  growth,  in  the  lowest  part  of  which 
is  seen  a  canine  tooth,  the  irritation  of  whose  presence  probably 
had  given  rise  to  the  development  of  the  cystic  disease. 


FIG.  80.— (From  Heath.)  FIG.  81.— (From  Heath.) 


The  affection  is  stated  to  be  more  common  in  the  upper  jaw 
than  in  the  lower,  but  all  the  teeth  in  either  jaw  seem  to  be 
liable  to  give  rise  to  the  disease.  The  symptoms  of  this  form 
of  tumor  can  be  no  different  from  those  of  other  expansions  of 
the  jawbone  by  cystic  formations,  but  a  very  reasonable  ground 
of  suspicion  that  the  case  is  one  of  dentigerous  cyst  may  some- 
times be  found  in  the  fact  that  the  teeth  are  not  normal  in 
number  or  in  character.  This  point  is  not  one  of  mere  patho- 
logical curiosity,  for  it  has  a  direct  and  most  important  bearing 
on  treatment,  as  it  must  be  evident  that,  if  the  disease  depends 
upon  the  presence  of  a  misplaced  tooth,  it  will  not  be  effectu- 
ally cured  until  that  tooth  is  found  and  removed. 


308  TUMORS   OF   BONE. 

Cystic  growths  not  directly  connected  with  the  teeth  are 
not  uncommon  in  both  upper  and  lower  jaws ;  though,  from 
Mr.  Heath's  account  of  them,  I  infer  that  they  are  more  fre- 
quent in  the  lower.  They  may  be  spontaneous  in  their  origin, 
as  in  one  case  reported  by  Mr.  Coote,  where  the  disease  was 
congenital ;  or  they  may  have  their  origin  in  some  injury  of  the 
alveolar  substance ;  or,  as  is  perhaps  most  commonly  the  case, 
they  may  originate  from  the  irritation  of  defective  teeth,  or 
stumps,  which  are  allowed  to  remain  in  sockets  which,  perhaps 
for  years,  have  been  more  or  less  constantly  in  an  inflamed  con- 
dition. They  may  be  unilocular,  which  is  by  far  the  most  com- 
mon form  (Fig.  81) ;  or  they  may  be  multilocular,  and  occasion- 
ally proliferous.  This  was  the  fact  in  Mr.  Coote' s  congenital 
case,  and  on  opening  the  tumor  it  was  found  to  "  be  filled  with  a 
regular  nest  of  cysts,  one  placed  within  the  other."  Another 
case,  of  Dr.  Robert  Adams,  quoted  by  Heath,  was  composed  of 
numerous  small  cysts  arranged  side  by  side:  "The  mucous 
membrane  covering  it  was  here  and  there  raised  into  rounded 
eminences  of  the  size  of  peas,  though  some  were  larger,  and  of 
a  purple  color.  The  tumor  was  composed  of  bony  cells,  of  a 
texture  as  fine  as  the  ethmoid  bone.  The  cells  generally  were 
of  such  a  size  that  each  might  be  capable  of  receiving  within 
it  a  garden-pea.  They  communicated  with  each  other,  and 
amounted  to  no  less  than  twenty-six  in  number.  They  were 
all  lined  by  a  pulpy,  very  red,  vascular  membrane,  and  con- 
tained an  albuminous  fluid  tinged  of  a  reddish  color,  apparently 
from  blood  dissolved  in  it." 

This  polycystic  form  of  growth  is  well  illustrated  in  Fig.  82, 
which  is  given  by  Heath  from  a  case  of  M.  Giraldes. 

These  cysts  sometimes  attain  a  very  great  size,  expanding 
the  whole  bone  into  a  great  tumor,  which  is  a  mere  bony  shell 
with  fluid  contents.  In  many  cases,  particularly  in  the  multi- 
locular form,  the  disease  extends  to  the  ramus  of  the  lower  jaw, 
quite  up  to  the  condyle,  and  even  into  the  coronoid  process. 
The  fluid  is  commonly  a  glairy,  transparent,  albuminous  mate- 
rial, sometimes  so  thick  as  to  flow  with  difficulty,  sometimes  a 
serous  fluid,  containing  flocculi  of  fibrinous  matter,  and  occa- 
sionally some  blood.  Their  growth  is  usually  slow  and  pain- 
less, and  patients  are  apt  to  be  urged  to  apply  for  relief  more 


TUMOKS   OF  THE  JAWS. 


309 


on  account  of  the  growing  deformity,  than  from  increasing  suf- 
fering. 

The  treatment  of  all  these  forms  of  cystic  development  in 
the  jawbones  is  nearly  the  same.  The  cyst  must  be  evacuated, 
and  the  cavity  kept  open,  and  then  by  tents  or  plugs  of  lint,  or 
by  stimulating  injections,  a  healthy  action  must  be  promoted  in 


FIG.  82.— (From  Heath.) 

the  lining  of  the  wall  of  the  cyst.  This,  happily,  can  generally 
be  accomplished,  and  when  aided  by  the  crushing  together  of 
the  expanded  bony  shell,  so  as  to  obliterate,  as  far  as  may  be, 
the  abnormal  cavity,  very  perfect  restoration  of  the  shape  of 
the  deformed  bone  may  be  hoped  for.  Some  writers,  as  Mr. 
Butcher,  of  Dublin,  recommend  the  free  removal  of  the  ante- 
rior bony  wall,  and  the  scooping  out  of  all  the  contents  of  the 
cavity ;  but  most  of  the  later  operators  have  found  that  they 
secure  success  quite  as  surely  by  a  more  moderate  procedure. 
Dr.  John  Mason  Warren,  of  Boston,  very  strongly  advocates 
this  less  severe  treatment  of  these  cases,  and  I  cannot  better 
illustrate  what  seems  to  be  the  received  opinion  on  this  point, 
than  by  relating  one  of  his  cases :  "  A  young  woman,  aged 
twenty-five,  w^ith  light  hair  and  blue  eyes,  and  delicate  skin, 
applied  to  me  in  the  spring  of  1862,  on  account  of  a  large  tu- 
mor involving  the  whole  right  side  of  the  lower  jaw  above  its 
angle.  The  tumor  was  of  a  globular  shape,  extended  back 
under  the  lobe  of  the  ear,  forward  so  as  to  encroach  upon  the 
cavity  of  the  mouth,  and  upward  so  as  to  press  upon  and  some- 


310  TUMORS  OF   BONE. 

what  to  overlap  the  zygoma.  The  external  surface  of  the  tu- 
mor was  smooth  and  shining,  slightly  oedematous,  and  she  suf- 
fered from  its  pressure  upon  the  surrounding  organs.  It  had 
commenced,  some  years  before,  by  a  swelling  at  the  root  of  the 
wisdom-tooth  of  the  right  side ;  and  the  inconveniences  caused 
by  the  pressure  had  become  so  great  as  to  lead  her  to  take 
measures  for  its  removal. 

"  Upon  consultation,  it  was  decided  that  a  portion  of  the  jaw 
would  require  removal ;  the  tumor  having  been  first  exposed 
by  an  incision  made  inside  of  the  mouth,  to  verify  its  character. 
The  following  operation  was  performed  under  the  influence  of 
ether.  An  incision  was  made  in  the  most  prominent  part  of 
the  tumor  in  the  mouth,  upon  which  a  large  quantity  of  glairy 
fluid  escaped.  Upon  passing  the  finger  into  the  opening,  it 
was  found  that  the  whole  jaw  at  this  point,  with  the  articulating 
and  coronoid  processes,  was  expanded  into  a  mere  shell,  at  some 
parts  as  thin  as  parchment,  and  destitute  of  osseous  substance. 
It  was  without  solid  contents.  Under  these  circumstances,  and 
considering  the  good  health  and  youth  of  the  patient,  it  was  de- 
termined to  make  the  attempt  to  save  the  jaw.  A  portion  was 
therefore  removed  from  the  sac ;  and  with  the  fingers  the  sides 
of  the  cavity  were  made  to  collapse,  so  as  to  come  in  contact 
with  each  other.  In  order  to  excite  still  further  irritation,  a  bit 
of  cotton  cloth  was  forced  into  the  interior,  and  the  end  left  pro- 
jecting into  the  mouth.  A  moderate  degree  of  irritation  fol- 
lowed ;  and  at  the  end  of  a  day  or  two  the  pledget  was  removed, 
suppuration  having  commenced  in  the  sac.  The  aperture  was 
dilated  from  time  to  time,  by  the  introduction  either  of  the  fin- 
ger or  of  a  bougie,  and  the  sac  injected  with  tincture  of  iodine. 
At  the  end  of  two  or  three  weeks  she  left  the  hospital  with  the 
tumor  reduced  to  about  one-half  its  original  size.  From  that 
time  until  the  present,  she  has  occasionally  visited  me  at  my 
house,  and  by  keeping  the  external  opening  free,  and  occasion- 
ally irritating  the  interior  of  the  sac,  a  solid  mass  of  bone  has 
been  deposited  anew,  and  the  jaw  has  resumed  somewhat  of  its 
original  shape. 

"  In  November,  1863,  I  again  saw  the  patient,  who  came  to 
consult  me,  not  about  herself,  but  about  a  friend.  All  signs  of 
the  tumor  had  disappeared,  and  the  jaw  had  regained  almost  its 


TUMORS   OF  THE  JAWS.  311 

natural  shape ;  but  a  small  aperture  still  existed,  at  the  site  of 
the  former  opening  into  the  mouth ;  and  a  glairy  fluid  was  oc- 
casionally discharged  from  it.  She  was  quite  well,  and  all  the 
functions  of  the  jaw  were  perfectly  performed." 

In  order  to  secure  the  more  perfect  obliteration  of  the  cyst, 
pressure  by  pads  acting  externally  by  the  force  of  springs,  as  in 
the  ordinary  truss,  has  been  found  to  be  occasionally  of  great 
assistance.  It  need  hardly  be  repeated  that,  in  all  cases  which 
depend  upon  the  irritation  of  misplaced  teeth,  the  offending 
cause  must  be  carefully  searched  for  and  removed. 

TUMOKS   CONNECTED  WITH    THE   GUMS. 

These  tumors  have  commonly  been  all  included  under  one 
head,  and  described  by  the  name  of  epulis,  from  two  Greek 
words,  signifying  upon  the  gum.  Much  difference  exists  among 
these  tumors,  however,  both  in  their  seat  and  nature.  Thus, 
some  of  them  are  mere  hypertrophies  of  the  gum-membrane, 
and  reach  a  formidable  size,  spreading  above  the  teeth,  which 
sometimes  they  almost  entirely  conceal,  projecting  from  the 
mouth,  very  vascular,  liable  to  ulceration,  and  producing  all  the 
inconvenience  and  distress  of  the  most  malignant  form  of  dis- 
ease. One  such  case  is  described  by  Dr.  Gross  in  his  "  System 
of  Surgery,"  and  another,  quite  similar,  is  fully  described  by  Dr. 
Salter,  in  his  article  on  "  Diseases  connected  with  the  Teeth," 
before  referred  to.  These  cases  seem  to  have  been  simple  hyper- 
trophy of  the  tissue  of  the  gum  of  both  jaws,  and  also,  in  some 
degree,  of  the  alveoli,  which  it  covers.  The  mucous  membrane 
participated  very  largely  in  the  hypertrophic  changes,  both 
papillae  and  epithelium  becoming  enormously  exaggerated  in 
their  anatomical  characters. 

Again,  some  of  these  growths  are  polypoid  in  their  form. 
These  often  spring  from  the  gum  at  the  side  of  or  between  two 
carious  teeth,  and  grow  quite  large,  with  a  pedicle  which  is  often 
entirely  concealed  by  the  mushroom-shape  of  the  growth.  Sev- 
eral of  these  projections  are  sometimes  found  in  the  same  indi- 
vidual, all  depending  upon  one  cause,  namely,  an  irritated  con- 
dition of  the  gums,  mostly  connected  with  defective  or  neglected 
teeth. 


312  TUMORS   OF  BONE. 

The  true  epulis  (Fig.  83)  is  a  firm  fibrous  tumor,  developed 
in  the  substance  of  the  gum,  usually  springing  from  that  part 
of  the  membrane  which  is  close  to  or  between  the  teeth.  It 

grows  slowly,  without  pain,  and 
often,  in  its  earliest  stages,  without 
tenderness,  and  it  extends  in  all  di- 
rections nearly  equally,  so  that,  as 
it  projects  from  the  mucous  surface, 
it  extends  in  a  nearly  equal  degree 
on  that  surface.  The  membrane 
covering  it  is  of  a  natural  appear- 
ance, and  rarely  becomes  the  seat 
of  ulceration.  As  the  epulis  en- 

FIG.  83.— (From  Heath.)  .  ITT 

larges  it  commonly  displaces  one  or 

more  of  the  teeth,  and  sometimes  grows  so  as  to  fill  up  and  oblit- 
erate the  sockets  of  the  teeth  that  have  thus  been  removed. 
After  a  time  the  bone  begins  to  participate  in  the  action,  be- 
coming vascularized,  spongy,  and  sending  prolongations,  in  the 
shape  of  delicate  spiculae,  into  the  fibrous  substance  of  the  tu- 
mor. In  the  older  and  larger  specimens,  some  detached  masses 
of  bone  are  occasionally  found  through  the  growth,  but  never 
in  such  a  degree  as  to  give  a  true  bony  consistence  or  character 
to  the  tumor.  The  course  seems  rather,  that  the  tumor  invades 
and  displaces  the  bone,  than  that  bony  formation  pervades  the 
softer  growth.  Their  naked-eye  features  vary  according  to  the 
consistence  of  the  growth.  In  the  harder  varieties  we  have  the 
firm,  glistening,  pearly- white  appearance  of  the  ordinary  fibrous 
tumor,  while  in  the  softer  forms  we  have  the  ruddy,  brown,  or 
greenish  yellow  of  the  myeloid  tissue.  The  microscopical  ap- 
pearances correspond  to  the  outward  features,  and  in  the  firm 
varieties  we  have  in  general  the  simple  fibrous  tissue,  more  or 
less  perfectly  formed,  while  in  the  softer  forms  we  have  an  abun- 
dance of  those  peculiar  elements  which  so  distinctly  characterize 
the  myeloid  growth.  Mr.  Saltcr  says:  "Epulis  tumors  are 
always,  I  believe,  a  form  of  'fibro-plastic;'  a  combination  of 
fibrous  tissue  and  myeloid  cells,  the  proportion  of  the  two  con- 
stituents varying  indefinitely.  In  general,  the  main  bulk  of  the 
tumor  consists  of  fibrous  tissue ;  but  sometimes  the  myeloid-cell 
element  preponderates,  and  may  form  the  major  part  of  the 
growth." 


TUMORS   OF  THE  JAWS.  313 

In  their  clinical  history  these  tumors  present  the  course 
which  their  histological  characters  would  indicate.  They  are 
never  malignant  in  the  true  sense  of  the  word,  and  yet  pertina- 
ciously recurrent  under  partial  extirpation.  They  are  therefore 
regarded  by  all  as  in  their  nature  benign.  Even  Virchow,  while 
he  insists  upon  absorbing  these  tumors  all  in  his  immense  class 
of  "  sarcoma,"  does  not  deny  that,  as  a  general  fact,  epulis  does 
not  assume  any  malignant  features. 

As  a  general  rule,  these  tumors  are  single ;  they  affect  the 
upper  jaw  rather  more  frequently  than  the  lower ;  they  never 
occur  in  jaws  which  have  no  teeth,  or  in  parts  of  jaws  where 
the  teeth  have  long  been  removed.  Mr.  Salter  gives  a  case 
which,  at  first  sight,  seemed  an  exception  to  this  rule :  "  One 
of  the  most  severe  examples  of  this  malady  which  I  have  seen, 
consisted  of  a  bilobular  mass,  the  size  of  a  large  walnut,  extend- 
ing on  the  left  side  of  the  lower  jaw  from  the  dens  sapientiaB 
to  the  canine  teeth,  the  four  intermediate  teeth  having  been  re- 
moved. The  excision  of  the  tumor  had  been  repeatedly  per- 
formed, but  it  always  returned.  Its  removal,  on  this  occasion, 
disclosed  the  remains  of  one  fang  of  the  first  molar  tooth  in  its 
very  axis ;  this  was  extracted,  and  the.  disease  did  not  again 
make  its  appearance." 

The  treatment  is  extirpation,  as  thorough  and  as  early  as 
possible.  If  removed  while  small,  the  operation  may  be  effec- 
tive without  touching  the  bone ;  though,  in  all  cases,  the  teeth 
immediately  involved  should  be  extracted.  If,  however,  the 
disease  has  been  of  long  standing,  and  has  therefore  involved 
the  underlying  bone,  then  any  thing  short  of  a  thorough  re- 
moval, not  only  of  the  tumor,  but  of  the  altered  bone  which 
forms  part  of  the  growth,  will  be  attended  with  disappointment. 
"With  the  gouge,  or  the  gnawing-forceps,  or  the  sharp  curved 
bone-nippers,  the  whole  of  the  soft,  spongy,  alveolar  bone,  which 
is  implicated,  can  easily  be  removed,  without  leaving  any  de- 
formity which  the  dentist's  art  cannot  repair,  and  without  at  all 
diminishing  the  strength  of  the  jawbone. 

SOLID   TUMOKS   OF   THE  JAWBONES.       , 

All  the  forms  of  bone-tumor  which  are  found  in  any  part  of 
the  skeleton  are  found  in  the  jaws.  Some,  however,  such  as  the 


314  TUMORS  OF  BONE. 

cartilaginous,  and  the  cancellous  exostosis,  occur  no  more  fre- 
quently in  this  situation  than  in  other  parts  of  the  skeleton ; 
while  others,  such  as  the  fibrous  tumor,  the  myeloid  tumor,  and 
the  ivory  exostosis,  are  rarely  found  in  any  other  bones.  These 
tumors  may  develop  themselves  by  growth  into  the  antrum, 
their  base  springing  from  its  walls,  or  they  may  originate  in  the 
bone  outside  of  the  antrum,  which  by  their  growth  is  more  or 
less  completely  obliterated.  In  all  these  cases,  if  the  tumor 
grow  from  within  the  bone,  the  striking  feature  is,  that  the 
outer  compact  tissue  of  the  jaw,  both  upper  and  lower,  is  dis- 
tended by  the  increasing  growth,  and  forms  a  thin  shell  which, 
during  all  the  early  periods  of  the  tumor,  entirely  encloses  it, 
and  gives  rise,  if  the  tumor  within  be  tolerably  soft,  to  the  sen- 
sation of  crackling  when  pressed  upon  by  the  finger,  which  we 
have  seen  to  be  so  characteristic  of  the  distention  of  the  antrum 
by  fluid  accumulation.  This  thin,  yielding  shell  of  bone  is  re- 
tained to  a  late  stage  in  the  growth  of  benign  tumors,  though 
sometimes,  if  the  increase  be  rapid,  the  bony  covering  is  pierced 
by  the  growth,  and  the  peculiar  feature  is  thenceforward  lost. 
This  symptom  is  sometimes  only  discernible  at  one  or  more 
points,  the  shell  at  other  places  being  still  so  thick  as  not  to 
yield  to  ordinary  pressure.  In  a  case  I  have  recently  seen  at 
the  Strangers'  Hospital,  of  myeloid  tumor  of  both  upper  jaws, 
I  found  the  crackling  at  only  two  points,  viz.,  just  above  the 
roots  of  the  molar  teeth  on  both  sides  in  the  upper  jaw. 

Many  of  the  growths  into  the  cavity  of  the  antrum  arise 
from  a  comparatively  small  base,  and  distend  without  other- 
wise implicating  its  walls.  This  peculiarity  sometimes  enables 
the  surgeon  to  remove  completely  and  thoroughly,  by  a  very 
simple  operation,  tumors  which,  from  their  formidable  size 
and  extensive  encroachments,  seemed  to  demand  the  removal 
of  the  whole  of  the  affected  jaw.  Sir  William  Fergusson,  in 
his  late  volume  on  the  "  Progress  of  Anatomy  and  Surgery," 
insists  very  strongly  on  this  point.  In  speaking  of  it  he  says : 
"  In  operations  on  this  bone,  as  on  the  lower  jaw,  and  as  with 
bones  in  other  parts  of  the  body,  I  take  the  liberty  to  protest 
against  the  doctrine  that  the  whole  bone  must  be  taken  away 
when  there  is  tumor  present.  Indeed,  it  is  largely  in  conse- 
quence of  what  I  have  seen  in  the  maxillae,  that  I  have  come  to 


TUMORS  OF  THE  JAWS.  315 

the  practical  conclusion,  that  total  excision  is  not  always  need- 
ful in  the  case  of  tumors." 

The  encroachment  of  these  tumors  upon  the  surrounding 
regions  is  an  interesting  feature,  both  as  to  diagnosis  and  as  to 
the  necessities  and  indications  of  operative  interference.  Most 
commonly  the  tendency  of  growth  seems  to  be  principally  in  one 
direction.  Thus,  we  have  the  tumor  expanding  the  anterior 
wall  of  the  bone,  and  appearing  prominent  on  the  face.  This 
is  the  direction  most  frequently  noticed,  and  in  many  instances 
the  extension  is  only  in  that  direction.  In  others  the  tumor 
invades  the  nasal  cavities,  sometimes  the  orbit,  sometimes  the 
roof  of  the  mouth,  and  sometimes  the  posterior  fauces ;  very 
rarely  all  are  successively  and  nearly  equally  encroached  on. 
The  case  above  alluded  to,  of  double  tumor  of  both  upper  jaw- 
bones, is  a  striking  example  of  this  uniform  distention.  The  tu- 


FIG.  84.— (From  Heath.) 


mor  makes  a  moderate  projection  forward  on  the  face,  it  bulges 
down  the  palatine  plate  on  both  sides  into  the  mouth,  it  has 
begun  to  push  up  the  eye,  and  can  be  felt  deep  in  the  orbit, 
and,  by  passing  the  finger  behind  the  velum,  a  rounded  edge  of 
the  growth  can  be  felt  very  distinctly  pressing  into  the  poste- 


316  TUMORS  OF  BOXE. 

rior  fauces.  These  encroachments  take  place  to  a  very  distress- 
ing extent  as  the  tumor  increases,  and  the  inconvenience  they 
cause  is  often  the  warrant  for  operation,  while  the  tumor  itself 
is  perhaps  neither  painful  nor  externally  deforming  in  any  very 
urgent  degree.  The  encroachment  upon  the  orbit  is  of  course 
mainly  important  in  regard  to  the  implication  of  the  eye,  which 
by  the  pressure  is  dislocated,  and  often  disorganized,  after  re- 
peated and  distressing  attacks  of  inflammation  ;  and  yet  some 
remarkable  instances  are  reported  of  very  great  displacement, 
causing  frightful  deformity,  without  loss  of  sight.  In  one  of 
Mr.  Fergusson's  cases  the  eyeball  was  thrust  forward  more  than 
an  inch  from  its  natural  position  in  the  orbit,  and  yet  the  sight 
remained  unaffected.  In  most  cases  the  sight  is  lost  very  early. 
The  projection  into  the  mouth  is  very  distressing,  by  interfering 
with  the  action  of  mastication,  and  indeed  by  preventing  the 
comfortable  introduction  of  any  kind  of  food.  When  to  the 
mere  bulk  is  added  the  fact  of  excoriation,  and  in  some  instances 
severe  and  painful  ulceration,  with  bleeding  on  the  slightest 
injury,  then,  indeed,  we  have  in  some  of  these  jaw-tumors,  grow- 
ing principally  into  the  mouth,  the  most  distressing  and  ex- 
hausting of  all  the  growths  which  are  not  essentially  of  a  malig- 
nant character.  The  encroachments  on  the  nasal  cavity  and 
on  the  posterior  fauces  are,  on  the  whole,  less  serious  in  their 
consequences. 

Of  the  general  characters  of  the  fibrous  tumors  of  bone  we 
have  already  given  an  account  at  page  256.  In  the  jaws,  where 
these  tumors  are  most  commonly  situated,  they  may  be  found 
growing  either  from  the  outside  of  the  bone,  and  then  they  are 
usually  confounded  with  the  periosteum,  from  which,  rather 
than  the  bone,  they  seem  to  be  an  outgrowth,  or,  in  other  cases, 
the  growth  is  from  the  central  part  of  the  bone  outward,  and 
in  the  increase  of  the  tumor  the  outer  compact  shell  of  the 
bone  is  often  distended  to  an  enormous  extent  over  the  mass. 
The  practical  difference  between  these  two  methods  of  growth 
seems  to  be  that,  in  the  periosteal  outgrowth,  the  diseased  mass 
cannot  be  cleanly  separated  from  the  bone,  which  is  gradually 
more  and  more  implicated  in  the  tumor ;  while,  in  the  growth 
from  within,  the  bone  covering  the  tumor  is  merely  in  contact 
with  it,  and  the  mass  can  readily  be  enucleated  from  its  bony 


TUMORS   OF  THE  JAWS. 


317 


connections,  except  at  the  point  from  which  it  springs.  This 
anatomical  difference  is  illustrated  in  Figs.  85  and  86,  taken 
from  Mr.  Paget's  "  Surgical  Pathology." 

Fig.  84,  from  Heath,  gives  the  external  appearance  of  the 
bone  as  its  walls  yield  before  the  growth  of  these  tumors. 

Of  all  the  tumors,  however,  which  affect  the  jaws,  the  mye- 
loid  is  that  which  has  attracted  most  the  attention  of  recent 


FIG.  85.— (From  Paget.) 


Fio.  86. — (From  Paget.) 


surgical  writers.  Though  occasionally  found  in  other  bones,  yet 
it  is  so  much  more  common  in  the  jaws  as  to  entitle  it  to  be 
considered  the  peculiar  tumor  of  this  region.  We  have  already, 
in  a  previous  chapter,  given  the  general  history  of  this  form  of 
tumor ;  there  only  remains  to  say  a  few  words  of  some  of  its 
features  as  affecting  the  jaws.  First,  they  almost  uniformly 
grow  from  the  inner  parts  of  the  bone,  either  the  cancellous 
tissue  or  the  antrum,  and  hence  they  are  almost  invariably  cov- 
ered with  the  thin  shell  of  bone  so  often  alluded  to.  It  is  true 
that  some  even  very  large  myeloid  tumors  are  connected  with 
the  gums,  and  secondarily  involve  the  jaw.  The  history  of 
these  cases  clears  up  their  nature,  and  shows  that  they  have 
commenced  as  true  epulis.  Their  growth  in  the  jaws  is  very 
slow,  sometimes  occupying  years  in  their  development — con- 
trasting, I  think,  somewhat  with  their  more  rapid  career  in 
other  bones.  A  very  striking  exception  to  this  general  fact 
occurred  in  a  case  recently  treated  by  my  friend  Dr.  Henry  B. 
Sands,  the  notes  of  which  he  has  kindly  placed  at  my  disposal : 
"August  14,  1870. — Operated  to-day  on  Emma  K.,  aged 
thirteen,  for  the  removal  of  a  tumor  of  the  right  superior  max- 


318  TUMORS  OF  BONE. 

ilia,  which  was  first  noticed  two  months  ago,  and  was  then  mis- 
taken by  the  parents  for  a  gum-boil.  When  examined  a  short 
time  afterward,  by  Dr.  Sampson,  it  was  thought  to  be  confined 
to  the  alveolar  process,  and  involved  the  sockets  of  the  first 
and  second  molar  teeth,  which,  though  sound,  were  loosened. 
Dr.  Sampson  extracted  the  teeth,  and  excised  the  tumor. 
Shortly  after  this  operation,  the  growth  reappeared,  and  an 
attempt  was  made  to  remove  the  diseased  parts  by  means  of 
the  knife  and  actual  cautery.  The  second  operation,  performed 
a  fortnight  ago,  does  not  appear  to  have  checked  the  growth, 
and  it  is  probable  that  in  neither  operation  was  extirpation 
thoroughly  accomplished.  When  the  patient  came  to  me,  a  few 
days  since,  I  discerned  a  soft,  elastic,  fleshy-looking  swelling, 
occupying  the  right  half  of  the  roof  of  the  mouth,  and  evidently 
involving  the  alveolar  process  of  the  upper  jaw.  Its  surface  was 
convex  and  slightly  ulcerated.  It  extended  from  the  curve  of 
the  dental  arch  inward  nearly  to  the  median  line,  and  back- 
ward as  far  as  the  posterior  edge  of  the  palate  process  of  the 
maxillary  bone.  Whether  it  occupied  the  antrum  I  could  not 
determine  previous  to  the  operation,  which  I  performed  this 
morning." 

The  operation  consisted  in  the  careful  and  thorough  removal 
of  all  tissue  that  appeared  diseased,  leaving  the  orbital  plate. 
The  operation  showed  that  the  mass  sprung  from  the  alveolar 
floor  of  the  antrum,  into  which  it  had  protruded  without  any 
attachment  to  its  sides  or  roof.  It  was,  therefore,  essentially 
alveolar  in  its  origin,  and  pretty  certainly  epuloid  in  its  earliest 
stages.  Posteriorly  the  limits  of  the  tumor  were  ill  defined ; 
it  was  followed  back  to  the  pterygoid  process  of  the  sphenoid 
bone. 

"No  cause  could  be  assigned  for  the  disease.  The  patient 
is  a  healthy-looking  country  girl,  and  inherits  no  morbid  ten- 
dencies. Her  parents  are  alive  and  well,  and  have  nine  living 
children."  Three  months  after  the  operation  she  was  heard 
from,  quite  well. 

Dr.  Delafield  makes  the  following  report  of  the  microscopical 
characters  of  the  tumor :  "  The  tumor  has  a  peculiar  loose, 
spongy  consistence.  It  consists  of  a  basement  stroma,  partly 
fibrous,  but  mostly  composed  of  small,  round  cells.  In  the 


TUMORS   OF  THE  JAWS.  319 

stroma  are  numerous  alveoli,  either  rounded  or  oval.  The 
alveoli  are  single,  or  a  number  of  them  are  found  close  together 
like  the  section  of  a  racemose  gland.  They  are  filled  with 
small  polygonal  cells."  These  represent  the  myeloid  element, 
and  are  present  in  great  numbers.  "Most  of  them  also  con- 
tain large  hyaline  bodies  of  globular  shape.  These  bodies, 
when  isolated,  consist  of  a  homogeneous  hyaline  substance, 
sometimes  wrinkled,  sometimes  on  a  pedicle  of  the  same  ma- 
terial, sometimes  strung  together  on  a  broad  band  of  the  same 
material."  Most  of  the  hyaline  bodies  in  the  specimen  shown 
to  me  were  oval  instead  of  round. 

Another  case,  which  I  saw  at  various  times  with  Dr.  Sands, 
illustrates  the  more  common  course  of  this  disease,  and  its  very 
great  tendency  to  be  reproduced  in  loco.  I  condense  from  Dr. 
Sands's  notes : 

Asa  Hill,  aged  thirty-eight,  presented  himself,  December  12, 
1863,  with  a  tumor  of  the  superior  maxilla  which  had  been 
growing  for  about  eighteen  months.  The  right  cheek  showed 
a  well-marked  prominence  over  the  body  of  the  superior  maxil- 
lary bone.  On  looking  into  the  mouth  a  large  tumor  is  seen 
projecting  into  its  cavity,  occupying  the  whole  of  the  jaw,  and 
extending  a  little  beyond  the  median  line.  Tumor  firm,  elastic, 
not  tender,  not  ulcerated.  Right  nostril  somewhat  obstructed. 
No  pressure  into  orbit.  The  upper  jaw  was  entirely  removed 
by  Dr.  W.  Parker,  and  the  patient  made  a  good  recovery. 

May  17,  1866. — The  disease  has  returned,  occupying  the 
walls  of  the  cavity  from  which  it  had  been  removed,  filling  the 
nostril,  and  involving  the  pterygoid  plate  of  the  sphenoid.  It 
was  again  removed  as  far  as  it  could  be  reached,  and,  to  the 
points  where  the  knife  could  not  safely  be  carried,  the  actual 
cautery  was  freely  applied.  The  wounds  healed  kindly. 

January  27,  1870. — The  disease,  doubtless  imperfectly  re- 
moved in  the  last  operation,  has  returned,  and  now  involves 
the  left  antrum,  while  a  large  projecting  mass  presses  down 
into  the  pharynx,  and  seriously  interferes  with  deglutition.  It 
involves  the  entire  left  superior  maxilla.  It  has  also  invaded 
the  right  tonsil.  The  whole  left  superior  maxilla  was  removed, 
and  every  particle  of  the  diseased  tissue  was  extirpated  as  far 
as  could  be  reached,  and,  as  before,  the  actual  cautery  was  thor- 


320  TUMORS  OF  BONE. 

oughly  applied  on  all  doubtful  spots.  He  recovered  from  this 
severe  operation,  though  the  wounds  in  the  mouth  were  not  all 
healed  when  he  died  of  pneumonia  on  the  23d  of  July,  1870. 
His  health  until  his  last  attack  had  been  very  well  maintained. 

The  microscopical  examination  of  the  last  tumor  removed 
was  made  by  Dr.  Delafield :  "  The  portion  of  the  tumor  which 
was  examined  was  of  uniform  consistence,  of  a  white  color, 
mottled  with  brown  (after  preservation  in  alcohol).  The  minute 
structure  of  the  tumor  is  a  fibrous  stroma  containing  cells.  The 
stroma  forms  in  some  places  a  very  delicate  net-work,  in  others 
thick  bands  of  fibrous  tissue.  The  cells  which  are  embedded 
in  the  stroma  are  round,  oval,  fusiform,  and  stellate  connec- 
tive-issue cells,  with  great  numbers  of  the  large,  irregular, 
finely-granular  masses,  filled  with  nuclei,  usually  called  myelo- 
plaxes." 

Many  years  ago,  while  curator  of  the  New  York  Hospital 
Museum,  we  received  a  donation  of  a  specimen  of  upper  jaw, 
which  had  been  removed  several  years  before,  and  which  was 
presented  to  us  by  the  operator,  Dr.  A.  H.  Stevens,  then  one 
of  the  surgeons  of  the  hospital.  He  had  removed  it  from  a 
private  patient,  and  had  preserved  it  in  his  own  cabinet  until 
the  formation  of  the  hospital  collection  began,  when  his  was 
one  of  the  first  contributions.  It  is  No.  48  in  the  catalogue. 
Mr.  G.,  the  gentleman  from  whom  it  was  taken,  was  a  man  in 
the  prime  of  life,  about  thirty- three  years  of  age,  one  of  our 
most  prominent  lawyers,  active  in  his  habits,  and  in  other 
respects  perfectly  healthy.  He  consulted  Dr.  Stevens  in  Au- 
gust, 1823,  "on  account  of  a  swelling  and  a  livid  redness  of  the 
gum  from  the  root  of  the  first  left  incisor  tooth  to  the  penulti- 
mate molar  of  the  upper  jaw.  The  membrane  lining  the  roof 
of  the  mouth  between  these  same  points  exhibited  the  same 
appearances.  Externally,  the  cheek,  under  the  orbit  of  the  eye, 
was  projected  forward,  so  as  to  fill  up  the  angle  between  the 
nose  and  the  cheek."  The  tumor,  with  a  considerable  portion 
of  the  jaw,  was  removed  August  14,  1823.  The  operation  has 
an  historical  interest,  as  being  the  first  one  of  its  kind  performed 
in  this  city,  and  one  of  the  first  anywhere  attempted,  Dr.  Jame- 
son's operation,  which  is  recognized  as  the  first,  having  been 
performed  in  1820.  Dr.  David  L.  Rodgers's  operation,  which 


TUMORS  OF  THE  JAWS.  321 

was  more  extensive  than  either,  involving  nearly  the  whole  of 
both  upper  jaws,  was  done  in  1824.  The  operation  was  done 
mainly  with  a  fine  saw  made  out  of  a  watch-spring,  and  did  not 
embrace  the  orbital  plate  of  the  maxillary  bone.  "  The  exami- 
nation of  the  removed  jaw  showed  a  fungous  tumor  occupying 
the  whole  antrum,  and  arising  by  a  broad  base  from  the  lower 
portion  of  it." 

Mr.  Gr.  recovered  without  any  drawback  from  the  operation, 
and  an  ingenious  dentist  of  that  day  fitted  to  the  gap  in  the 
jawbone  an  ivory  plate,  with  the  proper  teeth,  which  answered 
a  very  good  purpose,  entirely  concealing  the  deformity.  I  be- 
came acquainted  with  Mr.  G.  in  1848,  and,  though  much  with 
him,  I  never  suspected  that  he  had  lost  any  portion  of  the  bones 
of  his  face  until  he  told  me  of  the  fact,  and  showed  me  the  seat 
of  the  operation,  which  presented  a  perfectly  sound  and  healthy 
appearance.  He  died  of  pneumonia  in  1850,  then  approaching 
sixty  years  of  age.  He  lived,  therefore,  twenty-seven  years 
entirely  free  from  any  symptom  of  recurrence  of  the  disease. 

Dr.  Delafield  made  a  careful  examination  of  the  tumor  after 
it  had  lain  in  the  museum  of  Dr.  Stevens's  private  collection, 
and  afterward  in  that  of  the  New  York  Hospital  for  forty- 
seven  years.  His  report  of  his  examination,  made  in  1870,  is 
as  follows : 

"Adenoma  of  the  Antrum.  New  York  Hospital  Museum, 
No.  48. — A  tumor  fills  the  antrum,  and  replaces  the  superior 
maxilla  and  hard  palate ;  the  orbital  plate  is  absent  from  the 
specimen.  The  incisor  teeth  remain  in  place.  The  superior 
maxilla  retains  its  normal  shape,  but  the  bone  is  replaced  by 
the  new  growth.  The  tumor,  after  preservation  in  alcohol  for 
many  years,  is  mostly  of  a  loose,  spongy  consistence,  though 
some  parts  are  hard  and  fibrous.  A  few  spiculee  of  bone  are 
scattered  irregularly  through  it.  The  minute  structure  is  that 
of  follicles,  which  appear  round,  oval,  or  long,  in  different  sec- 
tions. These  follicles  are,  for  the  most  part,  very  regular  in 
shape  and  arrangement,  resembling  the  section  of  a  racemose 
gland.  The  walls  of  the  follicles  are  of  fibrous  tissue.  The 
follicles  are  filled  with  an  amorphous  mass,  probably  epithelial 
cells  destroyed  by  the  long  preservation  of  the  specimen.  In 
some  places,  however,  these  follicles  do  not  have  the  same 
21 


322  TUMORS   OF  BONE. 

regular  shape  and  arrangement,  but  are  found  very  large,  or 
small  and  isolated  in  fibrous  tissue." 

This  case  seems  to  me  a  very  interesting  example  of  an  ex- 
tremely rare  affection.  Adenoma  is  unknown  in  the  bones,  and 
its  existence  is  only  rendered  possible  in  the  jaws  by  their  ex- 
tensive connection  with  the  mucous  membrane,  in  the  numerous 
glands  of  which  it  seems  quite  reasonable  to  suppose  it  may 
have  had  its  origin.  The  microscopical  appearances  are,  it  must 
be  acknowledged,  somewhat  obscured  by  the  lengthened  macer- 
ation of  this  specimen,  but  enough  remains  to  make  its  char- 
acters unmistakable.  The  regular  alveoli,  enclosed  with  well- 
formed  fibrous  tissue,  can  hardly  be  mistaken  for  any  thing 
but  the  alveoli  of  epithelial  cancer,  and  this  idea  of  its  nature 
seems  to  be  refuted  by  the  manifest  and  well-proved  benignity 
of  its  course.  This  very  benignity,  attested  by  twenty-seven 
years  of  non-recurrence,  coincides  very  accurately  with  the  ac- 
knowledged good  character  of  the  adenomatous  tumors  wher- 
ever found. 

The  operations  necessary  for  the  removal  of  these  solid  tu- 
mors of  the  jaws  are  of  two  kinds,  viz.,  those  which  involve  a 
partial,  and  those  which  demand  an  entire,  resection  of  the 
bone.  In  a  considerable  number  of  cases,  particularly  where 
the  tumor  is  mainly  confined  to  the  alveolar  arch  or  to  the  nn- 
trum,  a  partial  resection  is  all  that  is  required  to  secure  the 
final  conditions  of  success.  This  partial  operation,  involving 
only  such  parts  of  the  bone  as  are  manifestly  diseased,  is  always 
to  be  preferred  to  the  more  severe  and  extensive  resection  of 
the  whole  jaw,  not  merely  because  it  is  a  less  serious  surgical 
operation,  though  that  consideration  should  have  great  weight, 
but  because  the  resulting  deformity  is  so  much  less ;  and  the 
inconveniences  of  the  loss  of  support  to  the  fauces  and  velum, 
as  well  as  of  the  wide  exposure  of  the  different  mucous  cavi- 
ties, are  not  so  disagreeably  experienced  by  the  patient.  The 
dentist's  art  has  reached  so  great  perfection  that  he  is  able  to 
supply  extensive  deficiencies,  if  only  he  has  a  base  to  work 
upon  ;  but  the  mutilation  caused  by  the  removal  of  the  whole 
of  the  upper  or  lower  jaw  is  a  serious  evil  to  which  the  patient, 
if  he  recover,  is  condemned  for  life,  and  for  which  the  most 
skilful  dental  mechanist  can  offer  but  an  imperfect  compensa- 


TUMORS  OF  THE  JAWS.  323 

tion.  It  becomes,  therefore,  the  duty  of  the  surgeon  to  meas- 
ure with  great  care  the  amount  of  destruction  he  inflicts  on 
the  bone  diseased,  and  limit,  with  scrupulous  precision,  this 
destruction  to  the  degree  necessary  to  secure  him  against  leav- 
ing behind  any  portion  of  the  diseased  growth. 

To  this  point  the  emphatic  cautions  of  Sir  William  Fergus- 
son  strongly  tend,  and  I  think  it  has  been  in  this  direction  that 
the  mind  of  the  best  surgeons  has  inclined,  ever  since  the  oper- 
ation of  excision  of  the  jaws  has  been  introduced.  Most  of 
the  operations,  of  which  I  have  had  any  knowledge  during  the 
past  few  years,  have  been  of  this  partial  character.  Sir  William 
Fergusson's  advice  is,  in  all  cases,  to  begin  the  operation  by  at- 
tacking the  tumor  at  its  central  points,  extending  the  area  of 
excision  as  the  parts  may  be  found  diseased ;  and  in  this  way 
we  have  proceeded  at  the  New  York  Hospital  with  Very  satis- 
factory success,  in  a  number  of  instances.  What  difference 
there  may  be  in  the  ultimate  result  of  partial  and  entire  exsec- 
tion,  only  extensive  and  careful  statistical  comparison  can  dis- 
cover, but  it  seems  to  me  that  only  the  ascertained  fact,  that  re- 
currences in  loco  are  more  common  after  well-conducted  partial 
than  after  complete  removals,  would  justify  us  in  inflicting  the 
greater  injury,  provided  there  seems  good  evidence  that  in  the 
lesser  operation  we  have  entirely  removed  the  disease.  It  can 
only  be  in  reference  to  the  benign  class  of  tumors  that  this 
question  has  any  interest,  for  it  is  well  understood  that  many 
of  this  class  have  that  local  inveteracy  by  which,  if  any  portion 
be  left  behind,  they  are  sure  to  be  reproduced  ;  assuming  thus 
a  character  of  semi-malignancy,  as  some  express  it,  or  local  ma- 
lignancy, as  I  think  it  is  better  described,  which  makes  the 
point  of  complete  removal  one  of  prime  importance.  In  the 
true  cancerous  affections,  any  operation  short  of  complete  re- 
moval would  rarely  be  justifiable. 

But,  while  we  give  full  weight  to  these  considerations,  the 
other  side  of  the  question  must  not  be  overlooked.  Modern 
pathology  explains  the  growth  of  some  tumors  by  an  infection 
of  the  surrounding  parts  with  the  juices  of  the  original  diseased 
mass,  in  such  a  way  that  there  is  supposed  to  be,  at  all  times, 
in  the  immediate  neighborhood  of  the  morbid  growth,  a  zone 
or  district  of  tissue  which,  while  not  yet  manifestly  altered  in 


324  TUMORS   OF  BONE. 

its  physical  appearances,  is  already  poisoned  by  the  infecting 
fluids  which  issue  from  the  growing  tumor.  This  view  is  pretty 
certainly  correct  for  some  cancers,  and  it  seems  reasonable  and 
even  probable  for  some  other  tumors  not  so  essentially  malig- 
nant in  their  nature.  If  this  be  so,  it  must  be  acknowledged 
that  the  risk  of  reproduction  is  very  considerably  diminished 
by  taking  away  the  whole  limb  or  organ  containing  the  focus 
of  disease,  and  modern  clinical  observation  has  abundantly 
proved  the  fact.  In  operating,  therefore,  upon  some  cases  of  a 
doubtful  nature,  it  is  the  surgeon's  duty  to  consider  whether  his 
anxiety  to  save  the  patient  fi-om  the  more  extensive  mutilation 
of  the  removal  of  the  whole  jawbone  may  not  lead  him  to  sac- 
rifice the  prospect  of  a  perfect  ultimate  recovery  ;  for  it  must 
not  be  forgotten  that  a  morbid  growth,  which  has  reappeared 
after  a  partial  removal  of  either  the  upper  or  lower  jaw,  does 
not  present  so  easy  or  so  favorable  a  subject  for  complete  extir- 
pation as  did  the  original  tumor. 

Again,  it  must  be  borne  in  mind  that  some  tumors,  particu- 
larly the  myeloid,  often  extend  themselves  by  minute  prolon- 
gations, or  even  detached  nodules,  so  small  as  not  easily  to  be 
detected  by  the  surgeon  at  the  moment  of  operation,  and  yet 
sufficient  to  insure  a  reproduction  of  the  mischief,  even  before 
the  wounds  made  by  the  partial  excision  have  entirely  healed. 
This  insidious  encroachment  of  the  myeloid  tumor  on  surround- 
ing healthy  parts  has  already  been  mentioned  in  the  chapter  de- 
voted to  the  general  study  of  these  growths,  and  it  is  nowhere 
more  strikingly  illustrated  than  in  the  spongy  and  alveolar 
structure  of  the  jawbones,  where  frequently  the  area  of  real 
disease  is  found  to  be  much  greater  than  the  apparent  tumor 
indicated.  In  all  such  cases  it  seems  very  certain  that  the  only 
safety  for  the  patient  must  consist  in  a  very  thorough  operation, 
if  not  in  a  complete  amputation  of  the  whole  infected  bone.  No 
general  rule,  therefore,  as  it  seems  to  me,  can  be  laid  down  on 
this  point  of  the  extent  of  operation  which  shall  be  performed. 
Each  case  must  be  judged  of  by  itself;  but  I  think  no  judicious 
surgeon  will  venture  to  decide  on  his  course  without  carefully 
considering  both  the  views  of  the  question  which  have  been 
above  presented. 

The  details  of  the  operation  will  necessarily  vary  with  the 


TUMORS  OF  THE  JAWS.  325 

case.  This  is  hardly  the  occasion  to  enter  into  the  various 
modifications  of  procedure  which  have  been  adopted,  or  which 
may  be  necessary.  I  confine  myself,  therefore,  to  a  few  sugges- 
tions of  general  practical  interest.  And  first,  with  regard  to 
incisions.  Many  of  the  partial  operations  can  be  conveniently 
and  easily  accomplished  without  any  incision  of  the  skin.  The 
tissue  of  the  lip  is  so  extensible,  that  with  proper  assistants,  and 
with  suitable  spatulse,  veiy  extensive  excisions,  and,  even  in 
small  tumors,  complete  extirpation  of  the  upper  jaw  might  be 
accomplished.  If  incisions  are  required,  then,  in  the  upper  jaw, 
the  most  useful  and  least  deforming  is  one  commencing  in  the 
median  line  of  the  upper  lip,  extending  round  the  ala  of  the 
nose,  and  up  along  its  side  to  the  inner  canthus  of  the  eye. 
Mr.  Fergusson  strongly  recommends  this  incision.  He  says : 
"  By  these  incisions  through  the  lip,  up  the  side  of  the  nose, 
and  along  the  lower  eyelid  as  far  out  as  may  be  useful,  say 
even  to  the  zygoma,  all  the  room  required  for  the  removal  of  a 
large  tumor  may  be  secured,  and  the  most  conspicuous  part  of 
the  cheek  left  untouched.  Another  great  advantage  which  I 
claim  for  these  incisions  is,  that  the  chief  vessels  of  the  surface 
are  all  divided  at  their  narrowest  points,  and  thus  haemorrhage 
is  less  severe  than  when  the  facial  artery  is  divided  in  the  mid- 
dle of  the  cheek,  as  in  the  common  incision."  Of  course,  it 
will  happen,  in  particular  instances,  that  more  extensive  or 
differently-planned  incisions  may  better  answer  the  surgeon's 
purpose ;  but  there  must  be  very  few  cases  in  which  the  in- 
cision given  by  Sir  "William  Fergusson  will  not  be  the  best, 
both  as  regards  convenience  of  operating  and  subsequent  de- 
formity. AVhen  the  flap  thus  marked  out  is  carefully  raised 
from  the  bone,  the  next  step  in  the  operation,  if  the  entire 
maxilla  is  to  be  removed,  is  to  separate  the  median  attachments 
of  the  two  bones  at  the  line  of  junction  along  the  palate.  This 
is  best  accomplished  by  a  fine  saw,  which  is  passed  into  the  nos- 
tril, and  by  it  the  hard  palate  is  divided  from  above  downward 
as  far  back  as  the  palate-bone.  Much  is  not  said  by  writers  on 
this  operation,  about  saving  the  palate-bone,  thereby  leaving  a 
support  for  the  velum,  and  preserving  the  shape  and  usefulness 
of  the  isthmus  faucium.  In  persons  past  middle  life  it  cannot 
easily  be  done,  as  the  palate  processes  of  the  superior  maxillary 


326  TUMORS  OF  BONE. 

and  palate-bone  are  so  firmly  welded  together  as  not  to  be  easily 
separated ;  but  in  young  people,  if  the  nature  of  the  tumor  will 
admit  of  it,  the  attempt  should  be  made,  and  will  often  be  suc- 
cessful. This  incision  had  better  be  completed  with  the  saw, 
and  will  be  much  facilitated  by  the  previous  removal  of  the  in- 
cisor tooth.  The  malar  bone  is  next  to  be  cut  through,  and  this 
is  perhaps  best  accomplished  by  cutting  the  compact  tissue  of 
the  surface  with  the  saw,  and  completing  the  section,  across  to 
the  anterior  end  of  the  spheno-maxillary  fissure,  by  the  strong 
cutting-forceps.  Then,  by  the  same  forceps,  passed  into  the 
nostril  and  orbit,  the  nasal  process  of  the  maxillary  bone  is 
divided,  and  we  have  only  remaining  the  attachments  to  the 
palate-bone,  and  through  it  to  the  sphenoid  behind,  and  to  the 
lower  edge  of  ethmoid  in  the  orbit.  These  attachments  are 
easily  broken  by  a  slight  rocking  motion  of  the  nearly-severed 
jaw,  and  this  can  very  conveniently  be  imparted  to  it  by  seizing 
it  with  the  double-toothed  "lion-forceps,"  first  suggested  by 
Sir  William  Fergusson  for  this  purpose.  These  motions  should 
be  cautious  and  gentle  at  first,  so  as  to  secure,  if  possible,  a 
loosening  at  the  natural  junctions,  and  afterward  more  forcible 
and  extensive,  as  may  be  necessary  to  detach  the  mass.  The 
soft  parts  which  hold  it  must  be  severed  with  the  scalpel,  or 
strong  curved  scissors,  care  being  taken  not  to  wander  away 
from  the  surfaces  of  the  bone  which  is  being  removed,  lest  im- 
portant nerves  and  vessels  be  unnecessarily  injured.  The  infra- 
orbital  nerve  should  be  treated  with  especial  consideration,  and 
no  violent  tractions  should  be  made  upon  it  before  it  is  cut. 
This  caution  as  to  the  early  careful  movement  of  the  loosening 
mass  is  of  special  interest  where  it  is  desired  to  save  the  palate- 
bone  from  coming  away  with  the  maxillary. 

Commonly,  no  large  vessels  are  wounded,  if  the  surgeon 
have  been  careful  in  hugging  the  bone  while  using  his  scissors. 
The  space  left  by  the  removal  is  so  large  and  open  that  the  ves- 
sels can  easily  be  secured.  I  have  once  seen  the  trunk  of  the 
internal  maxillary  opened  just  as  the  jaw  was  about  to  be  de- 
tached from  its  bed.  The  bleeding  was  profuse,  but  it  was 
easily  controlled  by  the  sponge,  and  without  much  trouble  safely 
secured  by  the  ligature.  I  have  never  seen  the  carotid  ligatured 
before  the  operation,  nor  has  it  ever  seemed  to  me  to  be  at  all 


TUMORS  OF  THE  JAWS.  327 

necessary.  The  wide-open  character  of  the  wound  makes  it 
easy  to  apply  the  actual  cautery  with  precision  to  any  points 
which  may  have  a  doubtful  look  after  the  main  disease  is  re- 
moved ;  and  with  us  it  has  been  a  common  practice  to  resort  to 
it  freely. 

The  removal  of  both  upper  jaws  has  now  been  several  times 
performed  with  success,  and  with  less  deformity  than  might  be 
expected  from  so  extensive  a  mutilation.  Dr.  David  L.  Rogers, 
of  this  city,  was  the  first  surgeon  to  attempt  this  operation, 
which  he  did  in  1824.  His  case  is  recorded  in  a  volume  of 
surgical  essays,  published  by  himself,  in  1849.  It  was  a  man, 
aged  thirty-four,  who  came  to  Dr.  Rogers  with  a  tumor  occu- 
pying all  the  front  of  the  upper  jawbone,  and  extending  into 
the  right  nostril,  with  the  loss  of  all  the  upper  incisors.  It  was 
growing  rapidly,  and  had  only  existed  about  six  weeks.  His 
operation  was  performed  May  10,  1824,  and  was  published  in 
the  third  volume  of  the  Physico-Medical  Journal  of  that  year. 
From  his  own  book,  published  fifteen  years  afterward,  I  take 
the  following  account  of  the  operative  procedure :  "  An  in- 
cision was  made  first  through  the  filtrum  of  the  upper  lip, 
which  was  dissected  from  the  tumor  and  alas  of  the  nose,  so  as 
to  turn  both  portions  of  the  lip  over  upon  the  cheek.  The  sec- 
ond incision  was  to  detach  the  cartilaginous  portion  of  the  sep- 
tum narium  from  the  top  of  the  tumor.  After  extracting  the 
first  two  molar  teeth  on  each  side,  a  fine  saw  was  used  which 
readily  divided  the  superior  maxillary  bone  including  the  pala- 
tine process,  the  two  incisions  meeting  at  the  palatine  suture. 
After  sawing  through  the  principal  bones,  the  tumor  was  easily 
removed,  although  it  extended  much  farther  back  than  was  at 
first  anticipated.  It  was  found  necessary,  during  the  operation, 
to  remove  the  two  inferior  turbinated  bones,  a  part  of  the  sep- 
tum narium,  the  vomer,  and  a  part  of  the  right  antrum."  The 
man  recovered  well,  with  a  moderate  amount  of  deformity. 
The  record  of  the  operation  is  lacking  in  anatomical  precision, 
and  the  extent  of  the  excision  is  left  somewhat  doubtful.  It 
can  hardly  claim,  however,  to  have  been  a  complete  extirpation 
of  both  upper  jaws,  while  to  it  must  nevertheless  be  accorded 
the  honor  of  being  a  pioneer  effort  in  the  field,  since  so  happily 
cultivated,  and  deserving  of  all  the  credit  to  which  its  bold- 


328 


TUMORS  OF   BOXE. 


ness,  originality,  and  success  are,  in  all  fairness,  entitled. 
In  operating  on  the  lower  jaw,  much  may  be  done  without 
any  external  incision.  Small  portions,  and  indeed  the  entire 
half  of  the  bone,  can  be  excised  through  the  mouth  without 
cutting  the  lip.  If,  however,  the  tumor  be  large,  and  particu- 
larly if  it  involve  the  ramus,  as  in  some  instances  of  cystic 
growth,  then  external  incision  is  indispensable.  The  incision 
usually  practised  is  one  parallel  with  the  base  of  the  bone,  and 
thrown  back  as  much  as  possible,  that  the  scar  may  be  out  of 
sight.  This  incision,  by  being  prolonged  on  the  cheek,  gives 
ample  room  even  for  the  removal  of  the  entire  bone ;  and  some 
writers  recommend  to  incise  the  lower  lip,  in  the  median  line, 
as  far  as  the  vermilion  border,  if  more  room  is  required.  The 
simple  vertical  incision  of  the  lower  lip,  prolonged  well  back- 
ward, is  said  to  give  all  the  space  necessary  for  any  of  these 

operations,  though  I  have  not  used 
it  nor  seen  it  employed.  After  sep- 
arating the  bone  carefully  from  the 
soft  parts  at  the  chin,  both  before 
and  behind,  and  extracting  a  central 
incisor  of  the  side  on  which  the  dis- 
ease exists,  a  chain-saw  (Fig.  87)  may 
be  passed  round  the  bone,  and  its 
division  accomplished  at  or  near  the 
symphysis.  Then,  with  a  sharp  and 
strong  scalpel,  closely  hugging  the 
bone,  the  attachments  are  to  be  di- 
vided, an  assistant  at  the  same  time 
managing  the  loosening  bone,  so  as 
to  keep  the  remaining  attachments 
in  a  state  of  tension.  This  part  of 
the  procedure  is  sufficiently  simple 
and  easy,  but  becomes  difficult  as  we  approach  the  condvle 
where  from  the  depth  of  the  part  it  is  not  easy  to  sever  the 
ligaments  of  the  joint.  This  difficulty  becomes  serious  when 
the  ramus  and  coronoid  process  are  distended  by  the  morbid 
growth,  and  it  sometimes  is  simply  impossible  to  finish  the  re- 
moval without  cutting  off  the  mass  as  near  the  joint  as  possible, 
and  then  with  sharp,  curved  forceps,  and  the  rongeur,  removing 


FIG.  ST. 


TUMORS  OF  THE  JAWS. 


329 


the  detached  condyle  piecemeal.  Fergusson's  lion-forceps  (Fig. 
88)  is  the  best  instrument  for  this  purpose,  giving  the  holder 
perfect  control  of  the  movements  of  the  fragment,  and  enabling 
him  to  change  the  tension  of  the  attachments  to  meet  the  opera- 
tor's knife.  The  facial  artery  is  the  principal  vessel  usually  cut 


in  this  operation,  and  this  is  cut  and  tied  at  the  time  of  making 
the  first  incision.  When  the  entire  jaw  is  to  be  removed,  it  is 
well  to  secure  the  tongue  from  falling  back  into  the  pharynx 
and  choking  the  patient,  as  in  several  of  the  earlier  recorded 
operations  it  threatened  to  do.  This  is  easily  accomplished  by 
passing  a  strong  double  silk  thread  through  the  substance  of 
the  tongue  about  an  inch  from  the  tip,  which  is  given  to  a 
careful  assistant,  whose  duty  it  is  to  watch  for  this  particular 
danger  and  obviate  it  by  drawing  the  tongue  firmly  forward. 
After  the  wound  is  brought  together,  and  the  muscles  have 
become  accustomed  to  the  loss  of  balanced  action,  there  is  but 
little  danger  from  the  swallowing  of  the  tongue. 

The  wounds  made  in  these  operations  should  be  lightly 
stuffed  with  soft,  well-picked  lint,  and  the  incised  integument 
brought  together  with  the  most  careful  accuracy.  Some  sur- 
geons prefer  the  silver  sutures.  We  have,  at  the  New  York 
Hospital,  used  the  fine  annealed  iron  wire  with  great  satisfac- 
tion ;  but,  in  my  later  operations  on  the  face,  I  have  been  much 
pleased  with  the  very  fine  silk  suture,  made  with  an  ordinary 
round  cambric  needle.  From  its  extreme  pliability,  the  silk 
adapts  the  edges  more  perfectly  to  each  other  than  any  metallic 
wire  can  do,  and  the  cambric  needle,  though  not  quite  so  easily 
thrust  through  the  skin,  makes  less  of  a  wound  than  the  ordi- 


330  TUMORS  OF  BONE. 

nary  surgical  needles,  and  leaves  much  less  of  a  scar.  If  the 
flaps  are  loose,  and  not  well  supported  by  the  parts  beneath, 
then  the  harelip  pins,  at  intervals  among  the  other  sutures, 
maintain  the  parts  more  perfectly  in  coaptation,  and  steady  the 
whole  line  of  suture.  No  adhesive  plasters  are  usually  neces- 
sary. 

Considering  the  magnitude  of  these  operations,  and  the  ex- 
tent and  importance  of  the  parts  involved,  they  are  very  suc- 
cessful in  their  result.  In  the  Medical  Times  and  Gazette 
for  September  3,  1859,  is  found  a  table  of  seventeen  cases  of 
resection  of  the  upper  jaw  for  various  diseases,  and  by  various 
operators,  and  of  the  seventeen  only  three  died.  The  rest  re- 
covered entirely  from  the  operation,  though  several  suffered  of 
course  from  a  return  of  the  malignant  disease  which  had  ren- 
dered an  operation  necessary.  I  think  our  own  operations  in 
New  York  would  show  a  not  less  satisfactory  result.  A  similar 
table  in  the  same  journal  shows  a  mortality  of  three  in  eleven 
cases  of  the  lower  jaw  operated  on  in  several  of  the  London 
hospitals.  These  tables  of  course  do  not  claim  to  represent  the 
exact  mortality  after  these  operations.  They  are  sufficient,  how- 
ever, to  indicate  that,  under  favorable  circumstances,  the  opera- 
tion is  a  safe  and  successful  one. 

The  following  case  I  saw  with  much  interest  with  my  friend 
Dr.  Goodwillie,  and  I  give  it  in  his  own  words.  It  is  an  inter- 
esting account  of  a  very  neat  and  successful  operation,  and  at 
the  same  time  a  good,  and  I  think  quite  a  rare,  example  of  the 
hard  form  of  osseous  growth  of  the  cancellous  variety  in  the 
alveolar  border  of  the  superior  maxillary  bone.  The  micro- 
scopical appearances,  of  which  a  drawing  is  given,  were  reported 
by  Dr.  J.  W.  S.  Arnold : 

"  Mrs.  B.,  aged  forty-four  years,  has  always  enjoyed  very  good 
health.  Some  six  years  ago  she  first  noticed  that  the  alveolus 
of  the  right  superior  maxillary  began  to  enlarge,  and  has  gradu- 
ally increased  to  the  present  time. 

"  She  has  experienced  no  pain,  and  desired  to  have  it  re- 
moved, as  from  its  large  size  it  has  become  a  source  of  great 
annoyance  to  her.  In  size  and  shape  it  very  much  resembles 
a  hen's  egg,  the  large  end  presenting  posteriorly.  It  extends 
antero-posteriorly  from  the  right  superior  canine  to  the  internal 


TUMORS  OF  THE  JAWS. 


331 


pterygoid  process ;  laterally  from  near  the  centre  of  the  palate  to 
the  maxillo-malar  fossa  forward  to  the  canine  fossa.  The  floor  of 
the  antrum  of  Highmore  was  encroached  on  to  a  slight  degree. 
The  mucous  membrane  over  the  surface  of  the  tumor  appeared 
a  little  lighter  in  color  than  is  common  to  the  alveolus ;  this 
was  no  doubt  due  to  the  tension  on  it  by  the  parts  below; 
otherwise  it  was  in  a  normal  condition.  In  the  surface  of  the 
tumor  could  be  seen  the  fangs  of  the  first  and  second  molars. 
The  canine  and  bicuspids  were  not  decayed.  Canine  and  first 
bicuspid  retained  their  normal  position  in  the  jaw.  All  the 
crown  of  the  latter  was  buried  in  the  tumor,  except  the  cusps. 
The  crown  of  the  second  bicuspid  could  all  be  seen,  but  the 
whole  tooth  was  raised  out  of  its  normal  position,  and  thrown 
inward  about  one-half  of  an  inch  (Fig.  89). 


FIG.  89.— (From  Dr.  D.  H.  Goodwill's  Collection.) 

"  There  being  no  pain  or  discharge  from  the  mouth  or  nose 
during  the  long  period  of  its  growth— its  apparent  firm  texture 
with  no  crepitation — together  with  the  excellent  health  the 
patient  has  always  enjoyed,  there  appeared  no  doubt  of  its 
benign  character. 


332  TUMORS  OF  BONE. 

"  The  following  cut  (Fig.  90)  represents  an  oral  saw  that  I 
devised  to  be  used  in  operations  on  the  maxillary  bones. 

"  To  a  handle  (a)  is  firmly  fastened  a  U  shank  (7>)  to  take  in 
the  cheek  or  lip,  and  thus  do  away  with  making  external  inci- 
sions. On  the  other  extremity  of  the  shank  is  a  square  socket 
to  which  are  fitted  saws  (or  knives)  of  different  sizes,  these  being 
firmly  fastened  by  a  thumb-screw  (c).  The  socket  being  square, 
allows  the  saw  (or  knife)  to  be  turned  and  worked  in  four  di- 
rections. It  is  only  necessary  to  unscrew  the  fastening  a  short 
distance,  to  turn  the  saw  in  the  desired  direction. 


G.TIEMANN  &  CO. 
C 


"  The  saw,  being  in  direct  line  with  the  handle,  can  be  very 
easily  guided.  The  backs  of  the  saws  are  thin,  while  the  teeth 
are  broad,  thus  giving  free  action. 

"On  June  20,  1871,  the  patient  was  placed  in  an  operating- 
chair,  and,  when  she  was  fully  under  the  anaesthetic,  the  head 
was  thrown  back,  and  the  mouth  kept  open  by  a  gag  between 
the  molar  teeth  of  the  opposite  side.  Taking  my  position  to  the 
back  and  over  the  head  of  the  patient,  I  placed  a  sponge  cut  to 
completely  fill  up  the  passage  to  the  throat,  and  held  in  position 
on  the  soft  palate  by  a  sponge-holder  to  prevent  the  blood  pass- 
ing into  the  throat  during  the  first  part  of  the  operation.  The 
patient  was  only  allowed  to  breath  through  the  nose,  which  she 
could  very  well  do.  No  external  incision  of  the  face  was  made. 
The  two  internal  incisions  were  made  from  behind  on  the  pos- 
terior prominence  of  the  tumor,  one-half  inch  on  each  side 
of  the  fangs  of  the  molars  forward  to  the  left  central  incisor. 
The  bone  was  now  laid  bare  by  stripping  the  soft  parts  with 
periosteal  denuders ;  the  latter  part  of  this  operation  was  to 
tear  the  palatal  muscles  from  the  posterior  part  of  the  hard 
palate  without  injuring  the  palatal  vessels  and  nerve  that  passes 
over  on  to  the  hard  palate  at  this  point.  There  being  no  further 


TUMORS   OF  THE   JAWS.      •  333 

use  for  the  sponge  on  the  soft  palate,  it  was  removed.  The  right 
lateral  incisor  was  now  extracted,  and,  by  its  socket  through  a 
little  to  the  right  of  the  centre  of  the  hard  palate,  so  as  to  save 
the  vomer,  a  section  was  made  with  the  oral  saw,  thus  dividing 
the  superior  maxillary  bones.  This  saw  was  now  removed  from 
the  socket  and  replaced  by  another  one,  half  as  long  (one  and 
a  half  inch),  the  teeth  of  which  were  changed  to  a  different 
angle,  so  as  to  allow  the  cheek  to  go  into  the  U-shank,  and  let 
the  saw  play  freely.  This  section  was  made  up  between  the 
tumor  and  the  internal  pterygoid  process  to  the  malar  bone, 
then  forward  through  the  canine  fossa,  dividing  also  the  inferior 
turbinated  bone,  to  meet  the  other  section  at  the  right  ala  nasi. 
After  the  saw  had  entered  the  antrum,  the  handle  of  the  saw 
was  more  rapidly  advanced  th  n  the  point ;  this  prevented  the 


FIG.  91.— (Osseous  tumor  from  Dr.  D.  II.  Goodwillie.  magnified  350  diameters.) 
Drawn  by  J.  W.  S.  Arnold,  M.D. 

point  of  the  saw  from  piercing  the  vomer  which  I  desired  to 
save.  By  these  two  sections  the  tumor  with  the  adjacent  bone 
was  removed  clean.  After  haemorrhage  had  stopped,  the  soft 
parts  were  closed  by  seven  silk  sutures.  On  the  fifth  day  four 
of  the  sutures  were  removed,  and  the  remainder  on  the  follow- 


334  '  TUMORS  OF  BONE. 

ing  day,  the  wound  having  healed  by  first  intention.  Four 
months  after  the  operation,  there  appears  every  indication  of 
a  new  formation  of  bone. 

"  Pathological  examination  of  the  tumor  shows  it  to  be  osse- 
ous. On  making  a  section  of  the  tumor  through  the  line  of 
the  teeth,  the  following  was  observed : 

"  At  the  apex  of  the  root  of  the  second  molar  tooth  there 
was  a  small,  soft  cyst  containing  pus,  and  for  a  short  distance 
surrounding  this  bone  appeared  quite  cancellated,  but  the  rest 
of  the  tumor  was  quite  dense.  The  pulps  of  the  canine  and  first 
bicuspid  teeth  had  still  some  vitality,  but  that  of  the  second 
bicuspid  was  dead.  The  pulp-chambers  were  decreased  in  size 
by  a  deposit  of  osteo-dentine  to  their  walls.  The  cementum  on 
the  fangs  of  the  teeth  was  hypertrophied.  A  large  nerve  en- 
tered the  tumor  on  its  buccal  side. 

"Microscopical  Character. — Composed  of  cancellated  tissue 
almost  entirely;  the  outer  rim  or  edge  of  a  thin  layer  of 
more  compact  bony  tissue ;  in  the  spongy  part  a  small  amount 
of  soft  marrow,  containing  the  usual  constituents  of  foetal  mar- 
row, that  is,  medullo  cells  and  myeloplaxes,  with  oil-globules." 
(Fig.  91.) 


PART  III. 
MALIGNANT  DISEASES   OF   BONE. 


IN  the  light  of  recent  microscopical  and  clinical  studies,  it  is 
not  easy  exactly  to  define  the  meaning  of  the  term  malignant 
as  applied  to  morbid  growths.  The  difficulty  does  not  arise  so 
much  from  any  want  of  precision  in  the  term  itself,  or  any  want 
of  appropriateness  when  applied  to  typical  and  well-marked  cases, 
as  it  does  from  the  varying  degree  in  which  the  qualities  it  ex- 
presses are  manifested  in  the  different  tumors  in  which  we  study 
it,  and  the  want  of  constant  correspondence  between  their  ana- 
tomical structure  and  their  clinical  history.  It  is  pretty  well 
agreed  among  pathologists  that  the  chief  clinical  features  of 
malignity  are:  1.  A  tendency  to  soften  and  ulcerate.  2.  A 
tendency  to  retiirn  after  extirpation,  even  the  most  complete. 
3.  A  disposition  to  appear  in  many  places  successively  in  the 
same  individual,  invading  many  tissues  in  the  region  originally 
affected,  and  developing  itself  in  many  distant  organs,  where  it 
seems  to  have  no  connection  with  the  original  disease.  These 
clinical  features  have  been  sought  to  be  associated  with  certain 
physical  forms,  which  pathologists  have  hoped  would  prove 
characteristic.  This  hope  has  not  been  fully  realized.  No  ana- 
tomical form  has  yet  been  found,  which,  of  itself,  is  distinctive 
of  cancer,  and  without  which  malignancy  cannot  exist.  No  as- 
sociation or  grouping  of  histological  elements  can  be  said  to  be 
absolutely  characteristic  of  malignancy ;  and  much  as  has  been 
done  by  Virchow,  Weber,  Waldeyer,  Beale,  and  Huxley,  in  un- 
ravelling the  laws  of  histogenesis,  no  mode  of  development, 
whether  as  to  source,  forms,  rate,  progress,  or  irregularities,  can 


336  MALIGNANT  DISEASES   OF   BONE. 

be  invoked  to  solve  the  question  of  the  clinical  history  of  every 
morbid  growth.  There  will  still  remain  some  obstinate  excep- 
tions, where  structure  and  history  do  not  correspond,  exceptions 
which  at  present  we  must  accept  as  indicating  to  us  how  superfi- 
cial is  our  knowledge  of  the  deepest  laws  of  vital  organization. 

"With  this  acknowledgment,  enougli  remains  upon  which  we 
may  build  our  classification  with  sufficient  precision  for  many 
practical  purposes ;  and  as  we  may  accept  those  above  given  as 
the  most  striking  and  constant  features  of  what  we  call  malig- 
nancy, so  we  have  certain  histological  and  histogenetic  charac- 
ters which  commonly  accompany  these  clinical  ones,  which  we 
may  with  practical  utility  and  safety  consider  as  the  physical 
condition  with  which  they  are  commonly  associated,  and  upon 
which  they  usually  depend.  Thus  malignant  growths  are  usually 
unlike  the  tissues  from  which  they  spring,  and  many  present 
features  which  are  unlike  those  of  any  tissue  found  in  the  nor- 
mal structures  of  the  body.  Again,  malignant  growths  have 
usually  their  elements  scattered  through  and  intermixed  with 
the  normal  tissues,  so  as  to  entangle  these  normal  tissues  with 
them  in  their  progress,  and  to  involve  them  in  the  destruction 
to  which  they  are  so  certainly  hastening.  These  two  features, 
heterology  and  infiltration,  are  well  marked  and  characteristic 
in  a  vast  proportion  of  cases  of  malignant  disease,  and  therefore 
may  be  considered  the  general  anatomical  features  of  these  affec- 
tions. Accepting  them  as  simply  the  general  characters  of  the 
disease,  we  may,  for  more  particular  study,  divide  the  great 
class  of  malignant,  or  cancerous,  or  carcinomatous  diseases,  for 
these  terms  are  generally  received  as  synonymous,  into  the  sub- 
classes of  scirrhous,  medullary,  epithelial,  colloid,  and  melanoid. 
Some  other  subdivisions  are  sometimes  made,  but,  in  reference 
to  the  bones,  I  believe  these  will  be  sufficient. 


CHAPTEK  I. 

SCTKKHUS,    OE    HARD    CANCER    OF   THE   BON'ES. 

As  a  primary  disease  of  the  bones,  scirrhus  is  extremely  rare. 
Several  authors  allude  to  the  possibility  of  its  occurrence ;  but 
I  have  not  myself  seen,  nor  have  I  met  in  any  published  ac- 


SCIRRHUS,  OR  HARD  CANCER  OF  THE  BONES. 


337 


count,  any  such  details  of  an  unequivocal  case  as  would  warrant 
my  presenting  it  as  an  example.  As  a  secondary  development, 
it  is  not  so  uncommon.  It  usually  lias  been  found  in  persons 
in  whom  the  cancerous  cachexia  is  far  advanced  ;  in  many  in- 
stances, the  patients  have  been  bedridden.  In  one  case  which 
occurred  a  few  years  ago  in  this  city,  the  patient,  an  old  lady, 
dying  slowly  from  the  disease,  primarily  developed  in  the  breast, 
had  been  confined  for  some  time  to  her  bed, 
when,  on  one  occasion,  on  attempting  to  turn 
or  to  raise  herself  in  bed,  one  of  her  thigh 
bones  gave  way,  and  some  days  after,  on  a 
similar  trifling  exertion,  the  other  also  broke. 
In  her  case  the  skeleton  was  very  extensively 
infiltrated  with  true  scirrhous  cancer.  The 
femora,  the  ribs,  the  humeri,  the  pelvic  bones, 
and  I  believe  all  of  the  bones  which  were  ex- 
amined, showed  traces,  more  or  less  consider- 
able, of  the  disease,  in  some  more  advanced 
than  in  others.  The  specimens  were  present- 
ed to  the  Pathological  Society,  and,  in  particu- 
lar, I  remember  that  the  ribs  were  so  soft  as 
to  be  flexible,  and  capable  of  being  cut  by  a 
scalpel.  In  this  case,  as  in  the  other  reported 
cases,  the  morbid  material  has  all  the  appear- 
ances of  the  disease  when  it  is  developed  in 
the  soft  parts,  both  to  the  naked  eye  and  un- 
der the  microscope.  It  is  sometimes  seen  in 
large,  more  or  less  rounded  tumors,  as  in  Mr. 
Paget's  case,  delineated  Fig.  92,  but  more  fre- 
quently, as  in  the  specimens  I  saw,  dissemi- 
nated in  small  nodules  through  the  cancellous 
tissue,  after  the  manner  of  an  infiltration. 
The  bone-substance  becomes  gradually  dis- 
placed,  or  rather,  probably  absorbed,  so  that 
fracture  from  slight  causes  is  extremely  likely  to  occur  ;  and, 
indeed,  it  has  been  noticed,  in  certain  rare  instances,  that  the 
whole  bone  has  disappeared,  leaving  the  periosteum  unchanged 
in  size  or  form,  but  filled  with  cancerous  material  instead  of  the 
original  osseous  tissue.  Mr.  Paget  speaks  of  a  case  in  which 
22 


9-2.-(From 


338  MALIGNANT  DISEASES   OF  BONE. 

"  a  cancerous  femur  was  broken  eight  months  before  death,  find 
the  new  bone  with  which  it  was  repaired  was  infiltrated  with 
cancer  as  well  as  the  original  textures." 

To  the  naked  eye  the  morbid  material  presents,  on  section, 
the  usual  bluish-white,  pearly,  shining,  semi-transparent  appear- 
ance of  hard  cancer  elsewhere.  Under  the  microscope,  the  cells 
present  the  same  appearances  which  are  characteristic  of  the  dis- 
ease in  other  parts.  Their  irregularity  of  form,  their  dim,  pel- 
lucid cell-wall,  their  large  nuclei,  commonly  single,  with  large, 
distinct  nucleoli,  are  features  well  marked ;  while  the  semi-fluid 
substance  in  which  these  cells  lie  enclosed,  as  in  a  stroma,  can 
be  squeezed  out  or  scraped  out  in  considerable  abundance. 
There  is  some  difference  of  view  among  pathologists  as  to 
whether  the  fibrous  element,  so  commonly  found  in  this  form 
of  cancer,  be  one  of  new  formation,  or  whether  it  be  only  the 
original  tissues,  distended  by,  and  enclosed  in,  the  growing  can- 
cerous mass.  This  question,  it  seems  to  me,  receives  some  light 
from  the  fact  that  this  fibrous  structure  is  sometimes  almost 
completely  absent  in  hard  cancer  of  the  bones.  In  some  of  the 
firmest  and  most  fibrous-looking  of  these  cases  there  is  no 
fibrous  tissue  to  be  discovered. 

Dr.  Delafield  made  a  careful  examination  of  some  of  the 
bones  removed  after  death  from  a  patient  of  Dr.  Sprague,  of 
Fordham,  who  had  died  of  cancer  of  the  breast  of  the  scirrhous 
form.  "All  the  long  bones  were  diseased;  had  become  bent 
during  life,  especially  one  femur.  Specimens  are  femur,  first, 
and  tibia,  last  affected.  Femur  is  much  bent,  and  tibia  not. 
Periosteum  and  cartilages  not  involved.  ^Nearly  the  entire  bone 
and  medulla  changed  into  a  firm,  white,  lardaceous  substance ; 
a  little  of  bone  of  shaft  and  cancellous  tissue  left.  Xew  tissue 
consists  of  dense  bands  of  white,  fibrous  tissue,  crossing  and  in- 
terlacing and  forming  round  and  oval  interspaces.  These  spaces 
are  mostly  empty,  but,  in  the  youngest  part  of  tissue,  are  filled 
with  polygonal,  nucleated  cells.  The  mamma  was  a  small,  con- 
tracted, hard  lump.  Only  fibrous  tissue  could  be  found;  no 
cells." 

In  another  case,  brought  into  Bellevue  Hospital  Xovember 
25,  1867,  fracture  had  occurred  of  the  right  femur  by  a  fall  in 
the  street  the  day  before  her  admission.  The  patient  was  a 


SCIRRHUS,  OR  HARD   CANCER  OF  THE  BONES.  339 

very  old  woman,  eighty-seven  years  of  age,  and  had  an  ulcera- 
ting carcinoma  of  the  breast  of  unknown  duration.  An  attempt 
was  made  to  treat  the  broken  limb,  but  she  rapidly  failed,  and 
died  December  8th. 

Autopsy. — "  Body  very  much  emaciated.  The  right  mamma 
is  the  seat  of  a  large  ulcer,  with  indurated  edges ;  the  axillary 
glands  are  much  enlarged ;  several  small  tubers  in  the  skin  near 
the  ulcer.  Head. — In  the  vault  of  the  cranium  are  three  round- 
ed places  where  the  bone  is  replaced  by  a  structure  resembling 
fibrous  tissue ;  the  periosteum  and  dura  mater  are  adherent  to 
these  places,  but  there  is  no  tumor.  In  the  bone  surrounding 
these  places,  the  diploe  is  filled  with  new  tissue,  and  the  bones 
thinned.  All  the  bones  of  the  skull  are  softer  than  natural. 
Brain  is  normal.  Lungs. — There  are  a  few  old  adhesions  over 
both  lungs.  Both  lungs  are  more  than  usually  pigmented.  The 
upper  lobe  of  the  right  lung  is  hepatized.  The  liver  has  hardly 
any  left  lobe.  There  are  gall-stones  in  the  bladder  and  ductus 
communis ;  the  latter  is  dilated  so  as  to  admit  my  finger  up  to 
one  quarter  of  an  inch  of  the  intestine,  where  it  is  obstructed. 
Spleen  small.  A  few  nodules  in  the  capsule.  Peritonaeum 
throughout  studded  with  small  white  tumors.  Kidneys,  in  both 
pelves  and  calyces,  dilated  and  containing  pus,  especially  the 
left.  Large  intestine,  its  walls  containing  many  small  tumors, 
over  which  the  epithelium  has  ulcerated.  Bones. — The  right 
femur  is  fractured  at  its  middle,  the  fractured  ends  much  dis- 
placed, and  bathed  in  pus.  At  the  point  of  fracture  the  shaft 
of  the  bone  is  thinned,  and  the  medullary  cavity  filled  with  a 
new  growth.  The  left  femur,  both  tibiae,  both  humeri,  the  sa- 
crum, and  one  os  innominatum,  contain  similar  deposits  of  new 
tissue  in  their  medullary  cavities.  The  scapulas,  ulnae,  radii, 
clavicles,  and  metacarpal  bones,  contain  no  such  deposit. 

"  Minute  Examination. — The  new  tissue  in  the  mamma  and 
in  the  tubers  in  the  skin  presents  the  same  appearance,  viz., 
potygonal,  nucleated,  epithelial  cells,  .018  to  .025  in  diameter, 
contained  in  round  and  oval  alveoli,  the  proportion  between  cells 
and  framework  varying  in  different  parts.  The  tumors  in  the 
peritonaeum  differ  from  these  in  their  greater  number  of  cells. 
In  the  long  bones,  the  tumors  are  situated  either  next  to  the 
shaft  of  the  bone  or  in  the  cancellous  tissue,  and  are  surrounded 


340  MALIGNANT  DISEASES   OF  BONE. 

by  red,  indurated  medulla.  This  red  medulla  is  composed 
largely  of  l  medullocelles.'  The  new  tissue  consists  of  a  pretty 
dense  fibrous  framework,  forming  alveoli  which  contain  cells. 
The  cells  are  the  same  as  those  found  in  the  breast.  There  are 
also  found  numbers  of  nuclei  adhering  together  and  surrounded 
by  protoplasma,  not  myeloplaxes.  In  some  places  only  cells  are 
seen.  In  the  cranium  the  cells  are  the  same,  but  their  arrange- 
ment is  somewhat  different.  The  fibrous  tissue  is  more  abun- 
dant, and  the  alveoli  small ;  some  only  containing  two  or  three 
cells,  others  much  larger ;  and  these  small  alveoli  may  be  close 
together,  so  that  it  looks  like  fibro-cartilage.  The  character  of 
the  cells  and  the  examination  of  a  sufficient  number  of  speci- 
mens destroy  the  possibility  of  this." 


CHAPTER  II. 

MEDULLARY,    OK   SOFT   CANCER   OF   THE   BONES. 

BY  far  the  most  common  form  of  cancerous  disease  of  bones 
is  the  medullary,  or  soft  cancer.  Indeed,  of  all  the  cases  of  medul- 
lary cancer,  the  bones  furnish  a  very  considerable  fraction.  Mr. 
Paget  gives  a  table  of  103  cases  of  external  medullary  cancer, 
omitting  those  of  the  uterus  and  other  internal  organs,  and  of 
these  21  were  in  the  bones.  Lebert  gives  a  table  of  447  can- 
cers, of  all  kinds,  of  which  35  were  in  the  bones.  M.  Tanchou's 
extensive  tables,  embracing  9,118  cases  of  all  kinds,  give  only 
38  to  the  bones.  This  small  fraction  might  probably  be  in- 
creased somewhat  by  adding  something  for  those  cases  which 
he  includes  under  the  head  of  thigh,  shoulder,  leg,  arm,  etc., 
some  of  which  were  doubtless  affections  of  the  bones.  Mr. 
Sibley's  tables  give,  of  520  cases,  15  of  the  bones,  and  Mr.  Baker, 
in  500  cases,  records  23  as  occurring  in  the  bones.  None  of 
these  are  to  be  relied  on  as  giving  an  accurate  statement  of  the 
relative  frequency  of  cancer  in  bones,  but  they  may  serve  to 
convey  some  general  idea  on  the  subject ;  and,  when  we  take 
into  account  the  fact  that  by  far  the  larger  proportion  of  all  are 
medullary,  we  have  arrived  at  some  rough  estimate  of  the  pro- 


MEDULLARY,  OR  SOFT  CANCER  OF  THE  BONES.     341 

portion  in  which  each  form  presents  itself  in  the  bones  as  com- 
pared with  the  soft  parts. 

These  statistical  statements  have  reference  to  cancer  in  all 
its  forms  and  all  its  conditions.  As  a  primary  disease,  how- 
ever, cancer  in  the  bones  is,  almost  without  exception,  of  the 
soft  variety.  The  primary  tumors  present  themselves  in  all 
parts  of  the  skeleton — Mr.  Paget  thinks  most  frequently  in  the 
thigh-bone — and  usually  affect  the  cancellous  tissue  in  the  first 
instance ;  often,  however,  extending  their  encroachments  to  the 
compact  substance,  which  is  gradually  incorporated  with  the 
growing  mass,  losing  always  its  compact  character,  and  becom- 
ing either  altogether  absorbed,  or  spread  out  into  a  spongy 
mass,  pervading  the  new  growth,  in  which  finally  no  trace  of 
the  original  compact  structure  can  be  discovered.  This  is  par- 
ticularly the  case  with  the  arm  and  thigh  bones,  and  it  is  in 
cancer  in  these  situations  that  we  most  often  have  fractures  oc- 
curring from  the  most  trivial  degrees  of  violence.  Most  com- 
monly the  primary  cancer  is  single,  and  in  the  shape  of  a 
rounded  tumor,  which  distends  before  it  the  outer  shell  of  the 
bone,  which  shell,  growing  thinner  and  thinner,  as  the  tumor 
enlarges,  it  sometimes  retains  until  it  has  attained  a  great  size, 
when  finally  the  cancerous  mass  breaks  through  its  covering, 
and  soon  all  traces  of  it  disappear.  The  tumor  may  either  be 
an  isolated  mass  of  medullary  substance  displacing  the  surround- 
ing bone-tissues,  or,  as  is  most  frequently  the  case,  it  is  an  in- 
filtration from  the  first ;  and  grows  as  such,  gradually  appro- 
priating to  itself,  and  enclosing  within  its  growing  mass,  what- 
ever bony  material,  whether  compact  or  cancellous,  it  comes  in 
contact  with. 

In  this  way  the  most  various  shapes  are  assumed,  and  the 
most  various  conditions  of  the  growth  itself  are  found.  The 
tumor  usually  projects  from  the  surface  of  the  bone  on  one  side ; 
sometimes  it  projects  unequally  on  both  sides,  as  in  the  cranial 
bones.  Sometimes,  as  in  the  heads  of  the  long  bones,  the 
whole  spongy  extremity  expands  nearly  equally,  and  often 
reaches  an  immense  size,  with  a  somewhat  symmetrical  form 
(Figs.  93,  94).  On  the  cranium  these  tumors  very  commonly  pro- 
ject from  the  surface  of  the  vault  in  the  form  of  evenly-rounded 
domes  or  hemispheres,  and  where  several  are  growing  close  to 


342  MALIGNANT   DISEASES   OF  BONE. 

one  another  the  head  presents  a  most  extraordinary  appearance. 
The  figures  99  and  100  are  taken  from  patients  who  died  of  the 
disease  developing  itself  internally,  while  the  tumors  seen  on 
the  head  were  slowly  increasing. 


FIG.  98.— (From  Billroth.) 

The  cut  surface  of  these  growths  presents  a  whitish,  pearly 
section,  in  which  an  arrangement  into  lobules  can  be  more  or 
less  distinctly  seen ;  the  lobules  varying  much  in  size,  and  still 
more  in  consistence  and  color ;  some  are  quite  hard  and  white, 
others  are  softer,  and  reddish  or  brownish  in  color.  Others  are 
so  soft  as  to  flicker  almost  like  jelly,  and  have  a  deep-red  or 
modena  color,  as  if  stained  deeply  with  blood.  In  other  points 
actual  extravasations  of  blood,  some  apparently  contained  within 
cyst-walls  of  a  sort  of  fibrous  tissue,  are  found,  giving  the  ap- 
pearances which  were  formerly  spoken  of  as  fungus  haematodes. 
The  tumor  is  usually  contained  within  a  capsule  formed  from 
the  periosteum,  often  much  thickened,  which  capsule  is,  during 
the  earlier  periods  of  the  growth  of  the  tumor,  fortified,  as  men- 


MEDULLARY,  OR  SOFT  CANCER  OF  THE  BONES.      343 

tioned  above,  with  the  thin  shell  of  compact  bone  upon  which 
the  periosteum  lies,  the  two  layers  at  first  expanding  together ; 
then,  as  the  tumor  increases,  the  bony  shell  giving  way  first ;  and 
afterward,  as  the  mass  softens  and  ulcerates,  the  periosteum 
disappearing  at  the  point  of  greatest  prominence ;  and  the  soft 
growing  mass,  now  released  from  the  support  of  its  hitherto 


FIG.  94— (From  Billroth.) 


FIG.  95.— (From  Billroth.) 


firm  envelope,  sprouts  without  restraint  in  whatever  direction 
it  is  least  opposed  by  surrounding  tissues.  If  the  tumor  have 
not  yet  reached  the  surface,  when  it  has  escaped  from  its  fibrous 
incasement,  then  we  find  it  invading  and  appropriating  to 
itself  all  the  softer  materials  which  it  encounters,  which,  becom- 
ing incorporated  with  the  growing  mass,  lose  all  identity ;  or, 
pushing  itself"  in  and  among  the  various  interspaces  where  press- 
ure is  the  least,  it  reaches  out  its  finger-like  processes,  extending 
often  much  deeper  and  much  farther  than  its  external  appear- 
ance would  lead  one  to  expect.  At  the  same  time  it  often 
seems  limited  by  encountering  a  firm  aponeurotic  layer,  against 
which  it  spreads  laterally,  and  adheres  to  it  without  involving 


344  MALIGNANT  DISEASES  OF  BONE. 

it,  at  least  for  a  considerable  period.  If,  on  the  other  hand,  the 
mass  has  reached  the  surface  when  the  fibrous  envelope  gives 
way,  then  we  have  the  proper  fungous  character  assumed,  with 
the  rapid  growth,  and  almost  as  rapid  destruction  of  the  pro- 
truding cancerous  material. 

The  relations  of  the  original  bone  to  the  growing  cancer 
have  already  been  alluded  to.  Here  the  processes  are  invari- 
ably those  of  destruction  and  disappearance,  more  or  less  com- 
plete, of  both  cancellous  and  compact  bone-tissue.  This  disap- 
pearance is  irregular,  however — at  some  points  being  further 
advanced  than  in  others,  so  that  at  different  parts  of  the  tumor 
we  may  have  either  much  or  very  little  of  the  disappearing 
original  bone  remaining.  With  these  irregular  remains  of  the 
skeleton  of  the  part  we  have  a  certain  amount  of  disposition  on 
the  part  of  the  tumor  itself  to  generate  new  bone.  I  think  this 
is  rarely  observed  to  any  great  extent  in  the  medullary  cancers 
of  the  long  bones,  but  in  those  affecting  the  skull  it  is  often 
very  marked.  In  the  maceration  of  the  head,  Fig.  100,  we 
found,  on  clearing  off  the  soft  parts,  and  drying  the  bones,  a 
most  extraordinary  and  beautiful  framework  of  delicate  spicular 
bone  springing  from  the  surface  of  the  skull,  which  was  itself 
eroded  and  partially  absorbed  wherever  the  tumor  had  grown 
from  its  surface.  These  slender  spiculae  and  thin  lamime  of  newly- 
formed  bone  were,  almost  all,  at  right  angles  with  the  surface 
of  the  bone  from  which  they  grew,  and  from  their  delicate  for- 
mation, varying  form,  and  beautiful  feathery  terminations,  made 
a  most  beautiful  preparation.  This  we  kept,  carefully  protected 
under  glass,  in  the  Xew  York  Hospital  Cabinet  for  some  years, 
but  it  gradually  disintegrated  and  fell  to  pieces,  so  that  now 
none  but  the  rougher  and  stronger  foundations  remain  of  the 
light  and  delicate  structure,  showing  by  its  destruction  how 
imperfect  and  feeble  it  was  in  its  organization.  This  form  of 
radiating  skeleton,  as  found  in  the  soft  cancer  of  the  skull,  is 
spoken  of  by  several  writers,  but  nothing  so  marked  is  often 
found  in  other  bones.  In  some  rare  cases  an  increase  of  bone- 
substance  is  found  from  the  beginning  of  the  disease,  giving  a 
hardness  to  the  growth  which  makes  it  quite  difficult  to  pro- 
nounce, without  microscopical  examination,  whether  we  have 
to  deal  with  a  cancer  or  an  exostosis. 


MEDULLARY,  OR  SOFT  CANCER  OF  THE  BONES.      345 

The  vascularity  of  these  cancers  is  usually  very  great,  and 
new  vessels  are  formed  with  surprising  rapidity.  These  vessels 
are  generally  very  large  in  size,  thin  in  their  walls,  tortuous 
and  often  varicose  in  their  course,  and  in  such  abundance  as  to 
be  out  of  all  proportion  to  their  amount  in  any  normal  tissue. 
It  is  on  account  of  this  disproportionate  development  of  vessels, 
large  -  and  small,  arterial  and  venous,  that  we  have,  in  many 
of  these  tumors,  so  active  a  circulation  that  the  pulsation  of  the 
arterial  vessels  often  gives  rise  to  the  suspicion  of  aneurism — 
a  suspicion  which  is  sometimes  strengthened  by  the  fact  that 
they  do  diminish  in  size  when  pressure  is  made  upon  the  main 
trunk  above  the  tumor.  This  diminution,  so  much  like  the 
subsidence  of  an  aneurismal  swelling,  under  the  same  manipu- 
lation, is  simply  due  to  the  fact  that  the  bulk  of  the  tumor  is  so 
largely  made  up  of  vessels  that  a  diminution  in  the  amount  of 
blood  they  contain  is  sufficient  to  produce  an  evident  decrease 
in  the  size  of  the  tumor  itself.  Hence,  also,  we  have  the  fre- 
quent extravasations  of  blood  into  the  substance  of  the  medul- 
lary mass,  and,  when  ulceration  has  taken  place,  the  same  abun- 
dance of  large  and  thin-walled  vessels  explains  the  facility  with 
which  haemorrhage  occurs,  and  the  alarming  extent  to  which  it 
sometimes  reaches. 

In  the  softer  cancers,  a  large  quantity  of  juice  can  be  scraped 
or  squeezed  from  the  cut  surface,  and  indeed,  by  moderate  and 
repeated  squeezings,  the  whole  solid  mass  of  the  tumor  may  be 
emptied  of  its  fluid  and  semifluid  contents,  and  then  appears  as 
a  flaccid,  whitish,  shreddy,  wet,  tow-like  mass,  which  bears  a 
surprisingly  small  proportion  to  its  original  size.  This  large 
proportion  of  fluid  matter,  retained  in  the  meshes  of  a  com- 
paratively small  amount  of  weakly  solid  stroma,  explains  very 
readily  the  deceptive  feeling  of  fluctuation  which  medullary 
cancers  in  the  soft  parts  so  often  present,  and  which  feeling  is 
not  by  any  means  rare  in  the  advanced  stages  of  the  disease  as 
it  occurs  in  .the  bones. 

The  microscopical  study  of  these  tumors  gives  us  nothing 
different  from  their  well-known  features  in  other  parts  of  the 
body.  Of  cells,  we  have  the  characteristic  multiformity.  Thus, 
we  have  the  ordinary  cell,  with  its  single,  rarely  double  nu- 
cleus, and  bright,  sometimes  multiple  nucleolus ;  these  cells 


346  MALIGNANT  DISEASES   OF  BONE. 

presenting  every  variety  of  shape,  sometimes  round,  sometimes 
flattened,  sometimes  elongated  into  processes  of  most  irregular 
outline.  These  are  mingled  with  a  large  proportion  of  what 
are  considered  as  free  nuclei,  though  Mr.  Beale's  researches 
would  lead  us  to  regard  these  as  cells  as  much  as  the  other 
forms,  these  free  nuclei  having  shapes  as  various  as  the  cells, 
and  often  presenting  a  close  approximation  to  the  spindle- 
shaped  cell,  of  which  we  have  seen  that  the  bulk  of  some  non- 
malignant  tumors  is  composed.  The  true  elongated,  spindle- 
shaped  cell,  with  nucleus  and  nucleolus,  is  not  uncommon,  but 
never,  so  far  as  I  know,  makes  up  any  considerable  portion  of 
the  mass.  Cells  also  occur  in  which  no  nuclei  can  be  seen,  and 
sometimes  we  have  the  large  cells  with  many  nuclei,  resem- 
bling the  peculiar  cell  of  the  myeloid  growth.  The  intercellular 
substance  is  softer  than  in  the  case  of  scirrhus,  and  a  good  deal 
of  the  cell-growth  seems  to  take  place  in  a  substance  which  is 
nearly  fluid.  Here,  however,  much  difference  prevails  in  dif- 
ferent specimens,  the  intercellular  substance  in  some  examples 
being  quite  firm,  and  in  extremely  small  amount,  whereas  in 
others  it  forms  the  bulk  of  the  growth,  is  almost  liquid,  and  has 
the  cells  floating  in  it,  much  as  pus-cells  float  in  the  liquor  pu- 
ris.  It  is  somewhat  characteristic  of  this  form  of  disease,  that 
all  these  varieties,  both  of  cell-formation  and  of  intercellular 
substance,  are  constantly  found  in  the  same  tumor,  and  often 
in  the  same  lobule. 

Much  has  been  said,  of  late  years,  of  the  fibrous  stroma  or 
framework  in  which  the  cancerous  material  proper  is  contained. 
The  alveolar  character  has  been  considered  by  many  able  ob- 
servers as  the  one  characteristic  anatomical  feature  of  cancer, 
by  which  a  ground  of  distinction  from  all  other  tumors  may  be 
maintained.  I  do  not  feel  prepared  to  accept  this  as  a  univer- 
sally applicable  anatomical  distinction,  yet  it  has  much  evidence 
in  its  favor.  Rokitansky,  as  long  ago  as  1852,  published  a  de- 
scription of  the  development  of  the  stroma  or  skeleton  of  can- 
cers, accompanied  with  beautiful  plates,  giving  his  ideas  with 
great  distinctness  and  minuteness.  He  describes  the  stroma 
of  cancer  as  composed  of  two  distinct  elements ;  one  somewhat 
of  a  fibrous  character,  and  the  other  made  up  of  cells  closely 
packed  without  any  distinct  fibrillar  arrangement.  These  two 


MEDULLARY,  OR  SOFT  CANCER  OF  THE  BOXES. 


347 


substances  are  arranged  in  the  form  of  bands  of  a  tolerably 
regular  size,  which  interlace  among  themselves,  leaving  spaces 
of  various  sizes  and  shapes,  in  which  are  contained  the  true 
cancerous  cells,  and  their  proper  intercellular  substance.  This 
stroma  he  considers  as  the  real  basis-substance  of  the  cancer, 
as  much  a  part  of  it  as  the  cells  themselves,  and,  pervading  all 
parts  of  the  diseased  mass  like  a  skeleton,  is  one  of  its  essen- 
tial anatomical  features  (Fig.  96).  Many  of  the  most  eminent 


FIG.  96.— (From  Paget.) 

pathological  anatomists  since  Eokitansky  have  given  a  descrip- 
tion of  an  alveolar  arrangement  of  the  stroma  of  cancer  vary- 
ing somewhat  from,  but  in  the  main  confirmatory  of,  his  views. 
Thus,  in  Cornil  and  Ranvier's  manual,  carcinoma  is  defined  to 
be  "  a  tumor  composed  of  a  fibrous  stroma  arranged  in  alveoli, 
which  form,  by  their  communication,  a  cavernous  system ;  these 
alveoli  are  filled  with  free  cells  contained  in  a  liquid  more  or 
less  abundant."  Billroth  entertains  views,  with  regard  to  the 
tumors  wilich  should  be  included  under  the  term  cancer,  in 
which  he  differs  somewhat  from  other  recent  writers,  but  he 
evidently  recognizes  as  an  anatomical  fact  the  alveolar  charac- 
ter of  the  cancerous  tumors  which  he  describes,  as  his  plate,  of 
which  Fig.  97  is  a  copy,  very  evidently  shows.  He  does  not, 


348 


MALIGNANT  DISEASES   OF  BONE. 


however,  seem  disposed  to  admit  the  alveolar  arrangement  as 
an  absolutely  characteristic  feature  of  cancer. 

The  clinical  history  of  soft  cancer  of  bones  presents  many 
variations  from  a  typical  case.  Most  frequently  the  disease 
commences  without  any  or  with  very  little  pain,  and  without 


FIG.  97.— (From  Billroth.) 

any  very  evident  assignable  cause.  Without  being  confined  to 
any  age,  it  is  most  common  at  a  much  earlier  period  of  life 
than  either  the  scirrhous  or  epithelial  form  of  the  disease.  In 
my  observation,  most  of  the  very  rapid-growing  cases  have 
been  in  young  adults.  In  one  very  remarkable  case  which  oc- 
curred in  the  New  York  Hospital,  and  of  which  we  have  the 
specimen  in  the  pathological  cabinet,  a  cancerous  tumor  of  the 
clavicle  and  scapula  proved  fatal  in  six  weeks  from  the  day  of 
its  first  appearance,  by  which  time  it  had  attained  a  size  of  one 
foot  in  diameter.  This  tumor  occurred  in  a  young  man  of 
eighteen  years  of  age.  Another  enormous  and  very  rapidly- 
developed  tumor  was  the  one  presented  in  Fig.  98.  This  was 
developed  from  the  clavicle  in  a  girl  aged  fourteen,  and  reached 
its  gigantic  size  within  a  few  months.  It  was  of  the  softer 
medullary  character,  and  to  the  last  showed  but  little  tendency 


MEDULLARY,  OR  SOFT  CANCER  OF  THE  BONES.      349 

to  ulcerate.     She  died,  worn  out  by  the  disease,  and  cancerous 
deposits  of  a  similar  character  to  those  of  the  large  tumor  were 
found  in  the  lungs.     She  had  also,  as  seen  in  the  woodcut,  a 
very  singular-looking  redundan- 
cy of  the  skin,  with  hypertrophy 
of  its  tissue,  on  the  right  arm, 
making  a  hanging  sort  of  bag  of 
thickened,  discolored  skin,  with 
numerous  strong  hairs  growing 
upon  it.     It  was  for  this  curious 
formation,  which  had  been  grow- 
ing for  several  years,  that  I  pre- 
sented her  to  the   Pathological 

O 

Society,  about  a  year  before  her 
death,  when  the  tumor  of  the 
clavicle  had  scarcely  begun  to 
show  itself.  The  tumors  shown 
in  Figs.  99  and  100  were  both 
young  men,  one  eighteen,  the 
other  nineteen  years  old. 

The  cause  of  these  growths 
cannot  generally  be  ascertained. 
Sometimes  an  injury,  as  a  blow,  is  the  starting-point  of  the  dis- 
ease, and  one  case  in  our  collection  followed  a  fracture.  No.  107 
is  a  picture  of  this  case,  which  was  briefly  this :  A  man,  twenty- 
two  years  old,  broke  his  arm  in  the  act  of  throwing  a  snowball. 
"  No  union  took  place,  and  at  the  end  of  six  months  he  entered 
the  hospital,  where  the  limb  was  removed  at  the  shoulder-joint ; 
an  encephaloid  deposit  having  meanwhile  taken  place  upon  the 
fractured  humerus,  so  abundant  as  to  form  a  large  fusiform 
swelling,  involving  the  greater  part  of  the  arm,  and  measur- 
ing at  least  twenty  inches  in  circumference."  Some  cases  are 
spoken  of  where  encephaloid  disease  has  attacked  carious  joints, 
where  the  products  of  old  inflammation  may  be  supposed  to 
have  been  the  nidus  in  which  the  cancer  originated.  In  by  far 
the  larger  number  of  cases,  however,  no  distinct  cause  can  be 
ascertained.  As  the  tumor  grows,  the  patients  suffer  pain  from 
its  distention  of  and  pressure  upon  the  surrounding  soft  parts, 
the  tumor  itself  remaining  free  from  pain  or  tenderness.  In 


FIG.  98.— (N.  Y.  Hospital  Museum.) 


350  MALIGNANT  DISEASES   OF  BONE. 

some  exceptional  cases  great  pain  is  experienced  from  the  ear- 
liest to  the  latest  stages.  The  tendency  to  ulceration  does  not 
seem  to  be  so  marked  in  medullary  cancer  of  the  bones  as  it  is 
in  cancers  of  other  parts  and  of  other  forms.  Many  of  the  largest 
tumors  I  have  seen  were  not  ulcerated  at  all,  and  those  which 
were  open  at  any  point  of  their  surface  seemed  to  have  become 
so  from  some  abrasion,  or  pressure,  or  some  other  accident 
which  had  determined  an  ulceration  where  it  would  not  other- 
wise have  occurred.  The  great  tumor  of  the  shoulder  had  a 
very  small  surface  of  ulceration  upon  its  summit,  which  only 
appeared  in  the  last  weeks  of  life.  The  tendency  of  most  of 
these  tumors  is  rather  toward  rapid  proliferation  of  the  cell- 
growths,  of  which  they  are  composed,  than  to  ulcerative  destruc- 
tion. This  ulceration,  however,  does  occur  in  some  cases,  usually 
preceded  by  a  bulging  of  the  tumor  at  one  or  more  points,  which 
become  very  vascular  in  their  external  appearance,  and  often 
very  tender  to  the  touch  as  the  ulceration  is  about  to  take  place. 
This  bulging  and  apparent  inflammation  is  the  accompaniment 
of  a  process  of  rapid  softening  which  is  going  on  at  that  point ; 
and,  when  the  surface  does  give  way,  we  have  an  ulceration  fol- 
lowed by  fungous  sprouting  forth  of  enormous,  soft,  spongy 
granulations,  rapidly  increasing  in  size  and  prominence,  bleed- 
ing fiercely  on  the  slightest  injury,  and  discharging  a  copious, 
thin,  bloody  ichor,  which  very  rapidly  exhaust  the  remaining 
powers  of  life.  The  condition  which  precedes  this  ulceration, 
viz.,  the  soft,  bulging,  very  vascular  prominence  of  a  certain 
part  of  the  surface  of  the  growth,  very  closely  simulates  the 
process  of  suppuration  in  its  external  features ;  and,  when  com- 
bined with  the  fact  that  a  pretty  rapid  and  quite  considerable 
softening  of  the  mass  occurs  at  the  protruding  point,  it  is  not 
wonderful  that  many  good  surgeons  have  been  deceived,  and 
have  plunged  a  bistoury  into  the  suspected  spot,  expecting  a 
free  escape  of  matter  to  follow  their  incision.  The  feeling  of 
fluctuation  is  so  perfect  in  these  cases  that  I  know  not  how  to 
discriminate  between  it  and  the  fluctuation  of  real  pus.  The 
mistake  is  an  unfortunate  one,  for  ulceration  and  fungus  are  very 
apt  to  follow  the  incision  ;  and  yet,  in  several  instances,  I  have 
known  such  a  cut  to  heal  as  quickly  and  as  soundly  as  if  it  had 
been  made  in  a  perfectly  healthy  part. 


MEDULLARY,  OR  SOFT  CANCER  OF  THE  BONES.      351 

During  all  the  earlier  part  of  this  disease,  particularly  if  the 
patient  do  not  suffer  much  pain,  the  constitution  does  not  seem 
to  experience  much  deterioration.  Some  of  these  patients,  with 
rapidly-growing  and  large  tumors  on  the  arm  or  leg,  will  keep 
about  their  ordinary  avocations,  and,  among  the  lower  classes, 
seem  sometimes  to  feel  very  little  anxiety  about  their  disease. 
One  of  the  largest  tumors  of  this  kind  that  I  have  ever  seen, 
occupying  two-thirds  of  the  whole  thigh-bone,  and  of  enormous 
diameter,  walked  to  our  college  clinique,  and  up  to  the  third 
story,  with  no  more  inconvenience  than  was  occasioned  by  the 
excessive  weight  she  had  to  carry.  In  the  later  stages,  after 
softening  begins,  and  particularly  after  fungus  has  protruded, 
the  system  gives  way  rapidly,  and  the  true  cancerous  cachexia 
occurs,  if  the  patient  live  long  enough  for  its  peculiar  features  to 
be  developed.  Secondary  deposits,  of  the  same  nature  as  the 
original  tumor,  are  found  in  the  liver,  the  lungs,  and  various 
other  internal  organs,  sometimes  in  immense  masses,  and  some- 
times very  extensively  diffused  over  various  organs  and  regions 
of  the  body.  Specimens  No.  557  and  558,  in  our  collection,  are 
instances  of  secondary  cancerous  developments  in  the  lungs  and 
pleura,  in  a  man  from  whom  the  thigh  had  been  removed  a  few 
months  before  for  a  large  medullary  tumor.  About  three  months 
after  the  amputation  he  began  to  suffer  from  pect6ral  symptoms, 
of  which  he  finally  died.  "  A  growth  of  fungus  hematodes  was 
found  to  have  involved  a  large  portion  of  the  lung,  while,  be- 
tween the  lower  surface  of  that  organ  and  the  upper  surface  of 
the  diaphragm,  which  is  pushed  down,  a  cavity  was  found  con- 
taining nearly  a  gallon  of  brownish-red  serous  fluid,  with  coagula 
and  shreds  of  lymph  floating  through  it."  This  cavity  was  that 
of  the  pleura,  whose  surface  was  studded  all  over  with  "  numerous 
rounded  and  flattened  masses,  soft,  and  of  a  white  color,"  which 
were  evidently  of  the  same  nature  as  the  tumor  originally  re- 
moved from  the  thigh.  No.  556  is  an  immense  secondary  medul- 
lary tumor,  developed  in  the  mediastinum,  and  compressing  the 
lungs  and  other  thoracic  organs  into  a  very  small  space.  This 
specimen  was  also  taken  from  a  man  who,  about  a  year  before 
his  death,  had  had  his  thigh  amputated  for  a  large  encephaloid 
tumor  of  the  femur.  Secondary  deposits  of  all  the  forms  of 
cancer  are  quite  common  in  the  bones. 


352  MALIGNANT  DISEASES   OF  BONE. 

It  is  well  known  that  all  of  the  forms  of  cancer  are  capable, 
under  certain  circumstances,  of  undergoing  a  change  for  the 
better.  This  change  may  be  shown  by  the  tumor,  heretofore 
progressive,  remaining  stationary ;  the  bulk  of  the  tumor,  in 
other  cases,  may  actually  diminish,  even  sometimes  to  the  ex- 
tent of  the  disappearance  of  all  signs  of  the  disease ;  the  surface, 
previously  deeply  ulcerated,  may  fill  up  with  healthy  graniTla- 
tions,  and  cicatrize ;  or,  lastly,  these  favorable  changes  may  be 
consequent  upon  a  process  of  inflammation  and  sloughing, 
whereby,  the  whole  tumor  being  destroyed,  a  sound  cicatrix 
may  be  secured.  These  flattering  phases  of  cancerous  life  are 
perhaps  best  and  certainly  most  frequently  seen  in  the  form  of 
the  disease  we  are  now  studying  ;  but,  it  has  so  happened,  that 
I  have  never  seen  any  good  exemplification  of  it  in  any  form 
of  cancer  of  the  bones.  It  doubtless  does  sometimes  occur  in 
medullary  tumors  of  the  bones ;  but  I  must  believe  it  to  be 
more  rare  than  in  any  of  the  forms  of  cancer  affecting  the  soft 
parts.  A  very  slow  growth  of  the  tumor  is  sometimes  seen,  as, 
in  one  instance,  where  a  woman  presented  herself  at  the  New 
York  Hospital,  with  a  large  tumor  of  the  tibia,  which,  she 
assured  us,  had  not  grown  at  all  for  twenty  years,  and  which, 
only  within  a  short  time,  had  given  her  any  uneasiness.  The 
limb  was  amputated,  and  the  tumor,  which  sprang  from  the 
anterior  face  of  the  tibia,  gave  the  most  unmistakable  evidence 
of  encephaloid  cancer. 

The  following  cases  illustrate  so  well  the  chief  clinical  fea- 
tures of  the  disease  we  have  been  considering  as  to  justify  me 
in  introducing  here  a  brief  outline  of  their  history.  The  first 
case  was  under  my  care  as  resident  surgeon  of  the  New  York 
Hospital,  Dr.  Gurdon  Buck  having  the  responsible  manage- 
ment of  it  as  attending  surgeon,  and,  from  his  very  full  and 
careful  notes,  dictated  at  the  time,  I  draw  my  material : 

Albert  Milderberger,  a  boatman,  aged  nineteen,  was  admitted 
into  the  New  York  Hospital,  December  14,  1839,  with  a  tumor 
of  the  size-  of  a  large  orange  covering  the  parietal  and  temporal 
regions.  "  In  the  month  of  May  last  preceding,  while  at  work 
on  board  a  vessel,  he  struck  his  head  against  the  boom,  as  he 
was  in  the  act  of  lifting  a  stove ;  but,  having  on  a  fur  cap  at 
the  time,  he  perceived  no  unpleasant  effects  from  the  blow,  and 


MEDULLARY,  OR  SOFT  CANCER  OF  THE  BONES.      353 

continued  his  work.  The  same  evening  he  noticed  a  soft  tumor, 
under  the  scalp,  of  the  size  of  a  walnut,  on  the  spot  where  he 
had  received  the  blow.  In  a  fortnight  it  increased  to  the  size 
of  a  Madeira-nut,  and  was  pronounced  a  wen  by  a  physician 
who  examined  it.  In  July  it  was  as  large  as  a  hen's  egg,  and, 
on  being  punctured,  it  discharged  a  pint  of  florid  blood  in  a  jet 
that  was  easily  arrested.  The  puncture  healed  in  two  days, 
and  the  size  of  the  tumor  was  diminished.  The  loss  of  blood 
relieved  a  headache  from  which  he  was  suffering  at  the  time. 
Pressure  was  now  applied,  during  four  or  five  weeks,  by  means 
of  a  piece  of  lead,  but  had  no  other  effect  than  to  flatten  the 
shape  of  the  tumor,  which  continued  increasing  in  size.  For 
four  weeks  preceding  his  admission,  very  powerful  pressure  was 
kept  up  by  means  of  a  piece  of  lead,  weighing  two  pounds, 
flattened  out  and  adapted  to  its  surface,  and  bound  firmly  to 
the  head.  This  caused  the  tumor  to  spread  at  its  base,  particu- 
larly along  the  lower  side,  toward  the  orbit  and  zygoma.  Five 
days  before  admission  it  was  punctured  a  second  time,  and  a 
pint  of  bright-red  blood  flowed  rapidly  in  a  jet,  without  dimin- 
ishing its  size.  The  blood  was  easily  arrested,  and  the  puncture 
healed  kindly. 

"  At  the  time  of  his  admission,  the  tumor  had  attained  a  for- 
midable size,  and  presented  the  following  characters  (Fig.  99) : 
It  rose  two  inches  above  the  surface  of  the  cranium,  standing 
off  in  an  oblique  direction  outward.  Its  base  was  of  an  oblong 
form,  and  extended  upward  to  within  two  fingers'  breadth  of 
the  median  line ;  backward  to  the  lambdoidal  suture ;  down- 
ward to  within  an  inch  of  the  ear,  and  forward  to  within  three 
fingers'  breadth  of  the  outer  margin  of  the  orbit.  Its  limits 
were  abrupt  and  well  defined,  except  about  one  fourth  of  its 
circumference  that  expanded  out  over  the  temple  in  a  superfi- 
cial soft  swelling  that  was  gradually  lost  near  the  outer  canthus, 
and  along  the  zygoma.  This  portion  appeared  after  pressure 
was  applied  the  second  time.  The  tumor  measured,  in  an  ob- 
lique direction,  forward  and  downward  over  the  summit,  seven 
inches  and  a  half.  The  surface  was  of  the  color  of  the  rest  of 
the  scalp,  and  sparsely  covered  with  hair.  Numerous  veins 
ramified  under  the  skin,  and,  when  pressure  was  made  on  the 
internal  jugular  vein,  they  became  swollen  and  prominent.  A 
23 


354  MALIGNANT  DISEASES   OF  BOXE. 

small  congeries  of  purple  arborescent  capillary  vessels  existed 
at  one  point  on  the  surface.  There  was  a  softened  spot,  of  the 
size  of  a  split-pea,  and  of  a  dirty-yellowish  color,  at  the  point 
where  the  last  puncture  had  been  made,  apparently  from  the 
formation  of  a  superficial  abscess.  The  tumor  was  tense  and 
elastic  in  every  point,  rather  softer  and  more  supple  in  front 


FIG.  99.— (From  N.  Y.  Hospital  Museum.) 

than  elsewhere.  ~No  fluctuation  could  be  felt,  nor  could  any 
diminution  of  its  size  be  produced  by  pressure.  The  pulsation 
of  the  branches  of  the  temporal  and  occipital  arteries  was  per- 
ceptible on  applying  the  hand,  but  there  was  no  pulsation  of 
the  mass.  On  applying  the  cheek,  however,  I  thought  I  per- 
ceived a  slight  movement  of  elevation  and  subsidence.  A  dis-  * 
tinct  bruit  de  souffiet  and  thrill  could  be  perceived  in  the  tempo- 
ral artery  above  the  zygoma.  A  solid,  roundish  lump  was  felt 
within  the  tumor  at  its  posterior  part ;  the  patient  himself  had 
noticed  it,  and  sometimes  had  noticed  two  lumps.  That  por- 
tion of  the  tumor  that  spread  upon  the  temple,  after  pressure 
was  applied  the  second  time,  was  soft  and  doughy,  except  at  its 
anterior  part,  where  there  was  a  circumscribed  portion  of  almost 
bony  hardness  that  seemed  movable  oh  the  cranium,  and  con- 
veyed to  the  touch  a  sensation  of  crepitus.  Pressure  on  the 


MEDULLARY,  OR  SOFT  CANCER  OF  THE  BONES.      355 

carotid  had  no  other  effect  than  to  stop  the  pulsation  in  the 
branches  of  the  temporal  and  occipital  arteries.  Patient  had 
no  pain  in  the  tumor  itself,  but  had  been  subject  to  pain  across 
the  forehead  for  six  years  previous,  which  came  on  at  intervals." 
His  general  condition  was  good ;  pulse  sixty-eight ;  appetite 
good,  and  bowels  regular. 

From  the  evident  vascularity  of  this  tumor,  it  was  thought 
best  to  try  the  effect  of  cutting  off  its  arterial  supply.  This 
was  done  by  Dr.  Buck,  on  the  21st  of  December,  by  applying 
a  ligature  to  the  common  carotid  artery,  and  afterward,  by 
circumscribing  the  tumor,  by  an  incision  through  the  scalp, 
about  an  inch  from  its  base,  which  encircled  the  whole  tumor 
except  about  two  inches  in  the  temporal  region.  The  vessels 
had  of  course  ceased  to  pulsate  when  the  carotid  was  tied,  but 
each  was  carefully  ligatured  as  the  incision  was  made.  The 
ligature  came  away  from  the  carotid  on  the  13th  day,  and  the 
incision  round  the  tumor  rapidly  cicatrized.  No  change  was 
produced  in  the  tumor,  by  this  thorough  operation,  except  the 
arrest  of  all  pulsation. 

January  4, 1840. — "  The  tumor  was  again  punctured ;  blood 
flowed  freely,  and  a  probe  passed  in  moved  easily  about  in  the 
substance  of  the  tumor,  as  if  its  substance  were  of  the  consist- 
ence of  brain.  An  attack  of  erysipelatous  inflammation  fol- 
lowed this  manipulation,  and  the  wound  remained  open,  dis- 
charging bloody  fluid." 

January  Ilth. — "The  punctured  opening  has  taken  on  a 
circular  form  of  the  size  of  a  split-pea.  Pressure  around  it  does 
not  force  out  any  discharge.  The  anterior  half  of  the  tumor  is 
softer,  and  its  covering  thinner,  having  much  the  feel  of  an 
abscess  near  the  surface ;  it  has  subsided  and  is  less  prominent." 
The  last  two  punctures  were  open  and  discharging,  and  a  probe 
could  be  passed  from  one  to  the  other.  A  bistoury  was  there- 
fore passed,  and  the  communicating  sinus  laid  open,  thus  largely 
exposing  the  centre  of  the  tumor.  This  exposure  of  the  mass 
of  the  tumor  was  followed  by  a  gradual  softening  and  disin- 
tegration of  the  exposed  portion,  pieces  sometimes  coming 
away  as  putrid  sloughs.  This  process  gradually  destroyed  the 
more  prominent  part  of  the  tumor,  but  it  nevertheless  extended 
at  its  base  until  it  became  converted  into  an  immense  promi- 


356  MALIGNANT  DISEASES  OF   BONE. 

nent,  but  not  fungous,  cancerous  ulcer,  the  level  of  which  was 
not  more  than  an  inch  above  the  surface  of  the  skull.  At  one 
or  two  points  the  bone  was  exposed.  Granulations  covered  the 
surface,  and  at  times  healthy-looking  pus  was  discharged  from 
it.  Occasionally,  severe  haemorrhage  now  began  to  be  pro- 
duced by  slight  causes,  which,  with  severe  epistaxis  now  and 
then  occurring,  reduced  his  strength  rapidly. 

In  May  he  left  the  hospital,  and  went  to  reside  at  his  sis- 
ter's house  in  the  city.  The  disease  continued  to  spread  over 
a  greater  area,  but  did  not  assume  at  any  time  the  fungous 
character.  He  died,  worn  out  by  frequent  haemorrhage,  in  No- 
vember, 184:0. 

Post-mortem  examination  showed  that  "  the  tumor  extend- 
ed from  the  middle  of  the  superciliary  arch  to  within  two  fin- 
gers' breadth  of  the  median  line,  in  the  occipital  region,  and 
from  the  sagittal  suture  above  to  the  angle  of  the  jaw  below, 
so  as  to  hide  the  right  ear,  the  cheek,  and  outer  half  of  the  eye, 
the  lids  being  drawn  down  with  it.  The  margin  of  the  tumor, 
along  the  sagittal  suture  and  as  far  forward  as  the  orbit,  pre- 
sents an  irregular  bony  ridge,  as  though  the  external  table  were 
pushed  outward.  The  suppurating  surface  of  the  tumor  was 
coated  with  dry  pus.  At  the  upper  part,  a  mass  of  dry  lint, 
impregnated  "with  blood,  adhered  to  the  surface,  where  it  had 
been  applied  several  months  since  to  arrest  haemorrhage,  and 
had  not  been  removed  for  fear  of  its  return.  The  circumfer- 
ence of  the  tumor  measured  twenty-five  inches.  Bony  spiculge 
could  be  felt  in  the  substance  of  the  tumor.  The  inner  table 
of  the  cranium,  as  well  as  the  outer,  was  very  extensively  ab- 
sorbed, and  the  tumor  had  pushed  before  it  the  dura  mater,  so 
as  to  encroach  very  much  on  the  brain.  A  prolongation  of  the 
diseased  mass  extended  into  the  sphenoid  fissure  and  zygomatic 
fossa.  The  surface  in  contact  with  the  dura  mater  was  of  a 
grayish  color,  and  of  a  firm,  jelly-like  consistence.  The  margin 
of  the  opening  in  the  inner  table  was  thin  and  sharp,  and  not 
pushed  inward,  while  that  of  the  outer  table  was  elevated  and 
uneven.  Besides  the  aponeurosis  that  invested  it,  the  tumor 
seemed  to  be  contained  in  a  strong,  fibrous  envelope,  that  di- 
vided it  into  lobes.  These  consisted  of  a  substance  of  firm, 
fleshy  consistence,  and  of  various  colors — portions  resembling 


MEDULLARY,  OR  SOFT   CANCER  OF  THE  BONES.  357 

coagulated  blood,  while  others  were  of  a  grayish  color.  The 
dura  mater  and  other  membranes,  as  well  as  the  brain  itself, 
were  apparently  healthy. 

"  The  left  kidney  was  six  times  larger  than  the  right,  and 
formed  an  irregular  nodulated  mass  of  the  same  morbid  struct- 
ure as  the  tumor.  The  outline  of  the  organ  could  be  recog- 
nized upon  the  anterior  surface  of  the  mass,  the  morbid  changes 
having  mostly  invaded  the  posterior  half  of  the  kidney." 

Both  specimens  are  preserved  in  the  hospital  cabinet.  The 
microscopical  appearances  are  not  noted  in  the  record. 

The  next  case  was  that  of  a  man,  nineteen  years  of  age,  who 
was  admitted  into  the  New  York  Hospital  in  June,  1856,  with 
an  enormous  tumor  of  the  thigh,  which  had  been  growing  about 
four  months.  It  occupied  the  lower  half  of  the  femur,  and  the 
limb,  at  its  largest  part,  measured  twenty-six  inches  in  circum- 
ference. The  thigh  was  amputated  on  the  24th  of  June,  and 
the  tumor  found  to  be  encephaloid  cancer.  He  did  well  after 
the  operation,  and  the  stump  healed  slowly.  On  the  26th  of 
December  following,  a  sudden  attack  of  oedema  of  the  face 
called  attention  to  a  soft  lump  on  the  side  of  the  head,  at  the 
junction  of  the  frontal  and  parietal  bones,  near  the  sagittal  su- 
ture. Stated  that  he  had  noticed  it  about  three  weeks  before, 
but,  as  it  gave  him  no  pain,  he  said  nothing  about  it.  It  is  of 
the  size  of  the  fist,  has  a  soft,  fluctuating  feel,  and  is  not  mova- 
ble on  the  skull.  Has  also  a  small  tumor  on  the  right  clavi- 
cle, which  gives  him  some  burning  pain,  and  is  tender  to  the 
touch.  Has  a  good  deal  of  headache,  especially  on  the  left  side 
of  the  head.  The  oedema  of  the  face  soon  subsided,  and  he 
seemed  as  well  as  usual.  Small  periosteal  swellings  were  noted 
on  the  third  and  fourth  ribs,  on  the  right  side,  near  their 
middle. 

January  4,  1857. — The  swelling  on  the  clavicle  has  disap- 
peared. The  large  tumor  of  the  head  is  also  subsiding,  and  his 
headache  is  much  relieved.  He  has  been  taking  iodide  of  po- 
tassa  in  increasing  doses  since  December  28th.  In  the  latter 
part  of  January  another  attack  of  oedema  of  the  face  came  on, 
without  chill  or  fever,  and  without  any  evident  cause,  and  passed 
away  as  before  in  a  few  days. 

January  24^A. — The  tumors  are  beginning  to  grow  again, 


358  MALIGNANT   DISEASES   OF  BONE. 

though  lie  is  taking  eighty  grains  of  potassa  daily.  The  medi- 
cine seemed  to  disorder  his  stomach,  and  was  reduced  to  five 
grains  three  times  a  day. 

February  20tA. — Another  tumor  has  sprung  up  over  the 
occiput.  The  original  tumors  are  increasing.  About  the  1st 
of  March  another  tumor  showed  itself  on  the  right  side,  over 
the  parietal  bone.  He  has  been  using  cod-liver  oil,  and  a  gen- 
eral tonic  and  invigorating  regimen.  He  now  suffers  great 
pain  running  down  the  left  arm,  requiring  large  anodynes  for 
its  relief.  In  April  a  swelling  without  distinct  tumor  appeared 
over  right  lower  jawbone.  The  tumors  of  the  head  are  gain- 
ing a  formidable  size.  That  on  the  clavicle  at  one  time  again 
almost  entirely  disappeared,  which  was  also  the  case  with  the 
swellings  on  the  ribs.  The  tumors  on  the  head,  after  their  first 
partial  subsidence,  steadily  but  slowly  increased. 

JLfay  12£A. — Tumor  of  jaw  diminishing.  From  this  time 
general  cancerous  cachexia  made  pretty  rapid  progress. 

June  22d. — He  is  noted  as  delirious,  and  his  eyesight  fail- 
ing; still  his  appetite  is  wonderful.  He  gradually  wasted  away, 
and  died,  July  27th,  with  no  other  cerebral  symptoms  than 
occasional  delirium  and  gradual  but  not  complete  loss  of 
sight. 

Autopsy. — The  weight  of  the  head  was  21£  pounds.  Its 
circumference,  measuring  horizontally  round  the  most  promi- 
nent points,  was  27J  inches.  The  perpendicular  prominence 
of  the  largest  tumor  from  the  surface  of  the  skull  was  about  8 
inches  (Fig.  100).  The  tumors,  of  varying  heights,  but  mostly 
of  a  rounded,  dome-like  form,  covered  nearly  the  whole  surface 
of  the  vault  of  the  cranium,  several  of  them  merging,  at  their 
bases,  into  one  another.  All  gave  the  feeling  of  fluctuation, 
and  when  cut  open  were  soft,  brain-like,  very  vascular,  with 
bony  spiculse  and  solid  bone-masses  scattered  about  through 
the  growth.  The  skull  was  perforated,  and  the  tumors  pressed 
down  upon  the  brain.  The  lungs  and  pleurae  were  studded 
with  firm,  white,  tumor-like  masses,  varying  from  the  size  of  a 
hazel-nut  to  that  of  a  walnut.  An  encephaloid  mass,  as  large 
as  a  child's  head,  was  found  in  the  right  iliac  fossa,  developed 
from  the  bone  upward  into  the  pelvis,  and  downward  so  as  to 
surround  the  head  and  neck  of  the  amputated  femur  in  a  sort 


MEDULLARY,  OR  SOFT  CANCER  OF  THE  BOXES. 


359 


of  cancerous  capsule.  The  other  tumors,  on  the  clavicle  and 
ribs,  noticed  before  death,  were  found  to  be  of  the  same  medul- 
lary character,  and  besides  these  several  small  tubera  were  de- 
veloped upon  the  bodies  of  some  of  the  vertebrae. 


FIG.  100.— (X.  T.  Hospital  Museum.) 


These  tumors,  after  maceration,  gave  the  beautiful,  radi- 
ated, feathery  skeleton  of  soft,  friable  bone-tissue,  described  at 
page  3i-i. 


360  MALIGNANT  DISEASES  OF  BONE. 

i 

CHAPTEK  III. 

EPITHELIAL   CANCEK   OF   BONE. 

MUCH  less  common  than  the  medullary,  and  considerably 
more  so  than  the  scirrhous  cancers,  the  epitheliomata  of  bone 
occur  sufficiently  often  to  have  been  carefully  observed  by  sev- 
eral writers.  As  a  primary  affection  it  is  rare ;  I  have  never 
encountered  one  which  was  recognized.  The  most  clearly- 
marked  case  I  find  recorded  is  one  which  was  admitted  into 
Guy's  Hospital,  under  the  care  of  Mr.  Cock,  in  May,  1858. 
The  patient  was  a  man  forty-five  years  old,  pale  and  cachectic- 
looking,  but  his  general  health  was  good  and  his  habits  regular. 
"  Twenty-six  years  ago  he  noticed  a  swelling  in  the  right  knee, 
which  continued  to  increase  for  some  time,  till  at  last  he  was 
unable  to  walk.  This  swelling  then  burst,  and  he  was  much 
relieved.  The  wound,  however,  never  healed,  and  was  some- 
times worse  than  at  others.  About  two  years  ago  he  fell  down 
and  struck  the  part ;  the  wound  then  became  rapidly  larger,  the 
bone  died,  and  at  last  he  came  to  this  hospital.  When  admit- 
ted, the  right  leg  presented  over  the  surface  of  the  tibia  a  large, 
sprouting,  epithelial  growth,  involving  nearly  the  whole  bone ; 
in  the  centre  was  a  deep  hollow,  which  excavated  the  bone, 
and  at  the  bottom  some  dark,  carious,  and  necrosed  bone  was 
visible." 

Mr.  Cock  amputated  the  limb,  through  the  lower  third  of 
the  thigh,  and  soon  after  the  man  left  the  hospital  cured. 

"  On  examining  the  limb,  it  was  clear  that  both  the  tibia 
and  the  integument  over  it  were  involved  in  one  mass  of  epi- 
thelial disease.  The  bone  was  for  the  most  part  dead,  and  in- 
filtrated with  the  elements  which  characterize  epithelial  cancer, 
or  epitheliorna.  The  sprouting  cauliflower-growths  from  the 
integument  presented  the  same  characteristics  ;  but  the  cells  in 
the  bone  were  very  well  marked,  and  proved  remarkably  beau- 
tiful microscopical  objects." 

Another  case  is  given  by  Mr.  Bryant,  of  the  same  hospital, 
of  a  man  who  had  an  epithelial  cancer  in  his  heel,  involving  the 


EPITHELIAL   CANCER  OF  BONE.  361 

os  calcis.  It  seems  very  probable,  however,  that  in  this  case, 
the  disease  began  in  the  scar  of  an  old  injury  of  the  integu- 
ments of  the  heel,  and  only  spread  secondarily  to  the  bone. 
The  same  suspicion,  it  must  be  confessed,  attaches  to  Mr.  Cock's 
case,  though  nothing  is  said  about  any  development  of  the  dis- 
ease in  the  skin  before  the  bone  became  aifected.  Billroth,  who 
makes  all  carcinomata  to  consist  of  epithelial  elements,  says : 
"  According  to  my  whole  histogenetic  view,  I  must  regard  it  as 
impossible  for  an  epithelial  cancer  to  occur  primarily  in  a  bone 
or  lymphatic  gland.  The  observations  that  I  know,  to  this 
effect  (in  the  lower  jaw,  on  the  anterior  surface  of  the  tibia,  in 
the  lymphatic  glands  of  the  neck),  do  not  seem  to  me  sufficient 
proof,  because  the  skin  and  mucous  membrane  are  so  near; 
there  may  have  been  an  insignificant  carcinomatous  disease  of 
the  skin  or  mucous  membrane  as  a  starting-point  of  the  disease, 
without  its  having  been  noticed." 

Secondary  developments  of  this  form  of  cancer  in  the  bones 
are  not  extremely  rare.  Lebert  says,  without  specifying  as  to 
the  primary  or  secondary  character  of  the  disease,  that,  in  nine- 
ty cases  of  cancerous  disease  of  bones,  he  found  it  six  times  of 
the  epithelial  variety.  Of  these,  four  were  in  the  lower  jaw, 
probably  secondary  after  cancer  of  the  lip,  one  was  in  the  upper 
jaw,  and  one  was  in  the  os  calcis. 

The  anatomical  characters  of  the  disease  are  well  marked. 
Microscojjically  they  consist  essentially  of  epithelial  cells  in 
varying  conditions  of  perfection,  and  very  variously  arranged 
in  their  relations  to  one  another.  Sometimes  the  epithelium  is 
contained  in  tubes  and  rounded  cavities,  on  the  internal  sur- 
faces of  which  it  makes  a  distinct,  well-arranged  layer,  so  regular 
and  orderly  in  its  appearance  as  to  make  it  difficult  to  be  sure 
we  are  not  dealing  with  true  gland-structure  (Fig.  101.)  At 
other  times,  the  epithelial  elements  are  massed  confusedly  with- 
out any  apparent  order,  and  for  no  useful  end.  Often  they  are 
rolled  upon  themselves  into  roundish  masses,  in  which  the  suc- 
cessive layers  of  flattened  epithelium  are  arranged  somewhat 
like  the  layers  of  an  onion  (Fig.  102).  In  short,  every  possible 
variety  of  arrangement  and  disarrangement  of  these  cells  may 
be  found,  and  upon  these  varieties  some  writers  have  founded 
numerous  subdivisions  of  the  disease.  It  is  sufficient  for  us,  as 


862  MALIGNANT  DISEASES  OF  BONE. 

students  of  bone-pathology,  to  be  aware  of  the  great  variety  of 
forms  into  which  the  epithelial  elements  are  in  different  cases 


arranged. 


Besides  these  typical  cells,  many  other  cells  are  often 
found  which  are  differently  described  by  different  authors. 
Paget  speaks  of  them  as  free  nuclei.  He  says :  "  Nuclei,  either 
free,  or  embedded  in  a  dimly  molecular  or  granular  basis,  are 


FIG.  101.— (From  Billroth.) 

commonly  found  mingled  with  the  (epithelial)  cells.  I  believe 
they  occur  in  the  greatest  abundance  in  the  most  acute  cases. 
They  may  be  just  like  the  nuclei  of  the  cells ;  but  usually,  among 
those  that  are  free,  many  are  larger  than  those  in  the  cells  ;  and 
these,  reaching  a  diameter  of  more  than  -^-^-^  of  an  inch,  at  the 
same  time  that  they  appear  more  vesicular,  and  have  larger  and 
brighter  nucleoli,  approximate  very  closely  to  the  characters  of 
the  nuclei  of  scirrhous  and  medullary  cancer-cells."  Billroth 
says :  "  But  we  must  here  state  that,  in  cancer-tumors,  besides 
the  epitheliums,  there  are  usually  numerous  young,  small, 
round  cells  which,  infiltrated  in  the  connective-tissue  portion 
of  the  tumor,  form  an  important  part  of  it.  This  small-celled, 


EPITHELIAL   CANCER  OF  BOXE. 


363 


connective-tissue  infiltration,  which  exists  in  varying  quantities, 
whenever  epithelial  proliferations  grow  into  the  tissue,  appears 
to  be  caused  by  a  sort  of  reaction,  and  to  be  the  result  of  the 
penetration  of  the  epithelial  new  formations  into  the  tissue,  ac- 
cording to  the  number  of  infiltrated  cells  and  their  future  fate, 


FIG.  102.— (From  Billroth.) 

as  well  as  the  degree  of  vascularity,  just  as,  in  inflammation,  it 
sometimes  leads  to  softening,  to  atrophy,  and  cicatricial  thicken- 
ing of  the  tissue.  In  some  cases,  this  small-celled  infiltration  is 
so  considerable  as  almost  entirely  to  hide  the  epithelial  new 
formation,  from  .which  it  may  be  very  difficult  to  distinguish  it, 
if  the  latter  be  small." 


364  MALIGNANT  DISEASES  OF  BONE. 

The  stroma  of  epithelial  growths  does  not  seem  to  be  con- 
stant or  always  well  denned.  In  many  cases,  and  I  think  always 
in  bone,  no  proper  alveolar  stroma,  such  as  has  been  described 
in  connection  with  medullary  cancer,  exists.  The  tissues  are 
merely  displaced  for  the  reception  of  the  new  deposit,  and  what 
fibrous  structures  we  find  traversing  the  morbid  mass  are  prob- 
ably derived  from  modifications  of  preexistent  normal  tissues. 
In  the  tubular  and  follicular  forms,  the  substance  of  the  tube  or 
follicle,  which  is  lined  by  epithelium,  may  be  supposed  to  be  a 
direct  derivative  from  the  normal  tissue,  of  which  it  is  usually 
only  an  exaggeration. 

These  tumors  are  permeated  with  a  certain  amount  of  fluid, 
"  cancer-juice,"  as  it  is  called ;  and,  as  the  cells  have  but  little 
cohesion  among  themselves,  there  is  easily  scraped  off,  from  the 
cut  surface,  a  milky  fluid,  which  is  made  so  by  containing  great 
numbers  of  the  epithelial  cells  floating  through  it,  suspended,  as 
in  an  emulsion. 

The  clinical  features  of  epithelioma,  wherever  situated,  are 
mainly  those  of  ulceration.  Most  epithelial  cancers  are  really 
cancerous  ulcers  from  their  commencement.  In  and  about  the 
base  of  these  ulcers,  the  cancerous  deposit  is  constantly  taking 
place,  so  that,  as  the  ulcer  grows,  the  cancer  increases ;  and  it  is 
rather  uncommon  for  an  epithelioma  to  gain  any  great  size  as  a 
tumor,  on  account  of  its  constant  tendency  to  ulcerative  destruc- 
tion. In  the  bones  these  features  are  somewhat  modified,  ac- 
cording as  the  deposit  reaches  the  osseous  tissue  from  an  ulcer- 
ated cutaneous  surface,  or  by  infection  from  a  distant  tumor. 
Of  cases  travelling  subcutaneously,  and  infecting  bones  deep- 
seated  and  distant  from  the  focus  of  disease,  Yirchow  gives  one 
instance,  in  a  man  aged  fifty-nine,  who  had  an  ulcerating  epithe- 
lial cancer  of  the  left  breast.  On  the  5th  of  February,  1853, 
the  left  breast  and  several  enlarged  axillary  glands  were  re- 
moved by  operation.  The  man  died  with  symptoms  of  pyaemia, 
February  21st.  At  the  autopsy,  marked  lesions,  characteristic 
of  pyaemia,  were  found.  The  ribs,  from  the  third  to  the  sixth 
on  the  right  side,  were  infiltrated  with  epithelial  cancer.  The 
vertebral  end  of  the  first  rib  on  the  left  side  was  also  similarly 
infiltrated.  In  the  upper  part  of  the  left  mediastinum  were 
found  several  small  nodules  of  epithelial  growth.  There  seemed 


EPITHELIAL  CANCER  OF  BONE.  365 

to  be  no  direct  communication  between  the  tumor  of  the  breast 
and  the  axillary  glands,  or  with  the  infiltrated  ribs.  In  such 
cases  as  this  there  could  be  no  chance  for  ulceration,  and  I  take 
it  for  granted  these  tumors,  if  the  man  had  lived,  would  have 
comported  themselves  much  as  other  deep-seated  cancers  do. 

In  by  far  the  larger  proportion  of  cases,  the  epithelial  dis- 
ease is  merely  an  extension  of  a 'similar  affection  from  the  mu- 
cous membrane  or  skin  which  covers  it,  and  hence,  as  far  as  the 
bone-disease  is  concerned,  it  may  be  said  to  commence  as  an  ul- 
ceration, in  the  same  sense  that  this  statement  may  be  made  of 
superficial  epithelioma  elsewhere.  Mr.  Stanley,  in  his  admirable 
book  on  "  Diseases  of  Bones,"  gives  a  number  of  cases  which 
he  calls  instances  of  phagedenic  ulceration  of  bone.  These 
cases,  very  graphically  described,  are  characterized  "  by  succes- 
sive abscesses  and  ulcerations  of  the  soft  parts  spreading  to  the 
periosteum,  and  thence  the  ulceration  extended  through  the 
bone.  Hard,  wart-like  granulations  arose  from  the  ulcerated 
surfaces  of  the  soft  parts  and  of  the  bone,  but  these  granulations 
had  no  disposition  to  cicatrize,  and  they  discharged  very  pro- 
fusely a  thin,  fetid  fluid.  In  this  state  I  have  known  the  dis- 
ease to  continue  many  years  without  the  slightest  effort  of  rep- 
aration." His  cases  were  all  in  the  tibia,  and  followed  some 
injury  which  had  produced  abscess  or  ulcer  over  the  bone. 

I  cannot  help  thinking  that  these  cases  were  in  reality  epithe- 
lial in  their  character,  and  I  am  the  more  strongly  led  to  that 
belief  from  the  following  case,  which  I  watched  with  great  in- 
terest, and  which,  in  all  its  clinical  features,  corresponded  very 
accurately  with  his  descriptions  : 

John  O'Brien,  aged  thirty-two,  was  admitted  into  the  New- 
York  Hospital,  September  10,  1854,  with  an  ulcer  on  the  front 
of  the  tibia,  connected  with  enlargement  and  disease  of  the 
bone.  At  the  age  of  twelve  years  he  had  received  a  severe, 
contused,  and  lacerated  wound  of  the  leg,  by  the  fall  upon  it  of 
a  heavy  piece  of  machinery.  The  laceration  was  mostly  on  the 
front  part  of  the  leg,  and  never  healed  entirely,  but  contract- 
ed down  to  a  small  ulcer,  which  gave  him  little  trouble.  Sev- 
eral times,  during  the  twenty  years  of  its  existence,  the  ulcer 
had  become  enlarged,  and  covered  with  proud  flesh,  and  given 
him  a  great  deal  of  pain,  particularly  in  soft  weather  and  at 


366  MALIGNANT  DISEASES  OF  BONE. 

night.  After  such  an  outbreak,  it  has  slowly  returned  to  its 
usual  quiet  condition.  The  last  of  these  attacks,  under  which  he 
was  suffering  when  admitted  to  the  hospital,  began  about  twelve 
weeks  ago.  While  thus  enlarged  and  ulcerating,  it  has  often 
bled  freely.  ~No  bone  has  been  discharged,  and  he  denies  ever 
having  had  syphilis.  The  ulcer  was  upon  the  middle  of  the 
tibia,  which  was  much  thickened  above  and  below,  as  was  also 
the  lower  part  of  the  fibula.  The  surface  of  the  ulcer,  half  the 
size  of  the  palm  of  the  hand,  irregular  and  prominent,  was 
formed  of  large,  hard,  wart-like  granulations,  giving  issue  to  a 
thin,  fetid,  watery  fluid.  The  probe,  on  being  pressed  down 
among  these  granulations,  entered  at  several  points  half  an  inch 
into  the  substance  of  the  bone,  and  encountered  rough  spiculae, 
particularly  round  the  margin  of  the  sore,  where  there  seemed 
to  be  a  border  of  sharp,  irregularly-ulcerated  bone,  from  which 
the  granulations  sprouted.  There  was  no  great  tenderness  or 
inflammatory  appearance  about  the  limb,  and  his  general  con- 
dition was  good.  On  the  23d  of  September,  finding  no  im- 
provement under  treatment,  Dr.  Buck  cut  down  and  exposed 
the  whole  surface  of  the  tibia,  and  found  that  the  wart-like 
granulations  sprung  from  the  bone,  which  was  hypertrophied 
above  and  below.  With  a  chisel,  the  whole  ulcerated  portion 
was  gouged  out  to  the  depth  of  about  half  an  inch,  leaving 
spongy  and  hypertrophied  bone  below,  which,  however,  seemed 
otherwise  sound.  At  one  point  the  gouge  opened  the  medul- 
lary artery,  which  bled  very  freely,  and  which  was  only  arrest- 
ed by  pressing  a  plug  of  wax  against  the  bleeding  orifice.  The 
wound  was  left  open  and  dressed  lightly.  November  29^A. — 
Xo  improvement  followed  the  operation.  The  wound  did  not 
assume  a  healing  action,  but  produced  anew  the  peculiar  wart- 
like  granulations,  bleeding  freely  from  the  slightest  injury. 
Several  large  pieces  of  bone  came  away,  and  the  ulcerative  ac- 
tions were  progressive  in  the  centre  of  the  sore.  His  general 
condition  was  rapidly  deteriorating,  and,  at  his  own  request,  the 
leg  was  amputated  just  below  the  knee. 

On  examination,  the  lower  two-thirds  of  both  bones  were 
found  very  greatly  hypertrophied.  At  the  point  of  ulcer  there 
was  a  loss  of  substance  of  the  bone  equal  to  more  than  one- 
third  of  its  diameter.  This  excavation  was  covered  and  partly 


EPITHELIAL   CANCER  OF  BONE.  367 

filled  up  with  cauliflower-like  granulations  containing  no  bone. 
The  bone-substance  seemed  to  be  irregularly  excavated,  and 
worm-eaten,  but  without  any  reparative  formation  of  new  bone. 
The  posterior  surface  of  the  tibia  showed  that  the  diseased 
action  was  penetrating  throughout  its  whole  structure.  It  was 
prominent,  with  irregular  nodules  of  bony  deposit  on  its  surface, 
and  the  substance  of  the  bone  gave  the  idea  of  being  infiltrated 
throughout  with  the  same  material  as  that  composing  the  granu- 
lations. The  same  substance  seemed  to  form  the  basis  of  the 
skin-granulation,  and  was,  in  several  places,  infiltrated  into  the 
muscles.  My  friend  Dr.  John  T.  Metcalfe  made  the  micro- 
scopic examination  of  the  tumor  for  me,  and  found  the  mass 
composed  mainly  of  cells.  In  the  fluid  pressed  from  the  bone- 
granulations  these  cells  were  of  various  characters.  There  were 
many  small,  round  cells,  with  well-marked,  sometimes  double, 
nuclei ;  others  larger,  with  branching  processes ;  others  spindle- 
shaped,  but  among  them  a  considerable  proportion  of  large,  flat, 
single  nucleated  cells  which  were  manifestly  epithelial. 

The  patient  made  a  good  recovery,  and  when  the  stump  was 
healed  he  left  the  hospital ;  but  already  some  enlarged  lym- 
phatics in  the  groin  looked  suspicious.  On  the  llth  of  March  I 
was  sent  for  to  see  him,  and  found  him  greatly  changed.  The 
swellings  in  the  glands  of  the  groin  had  grown  to  be  immense 
tumors,  which  had  broken  out  into  foul  and  fungous  ulceration, 
which  were  rapidly  destroying  their  surface,  while  their  base  was 
being  as  rapidly  increased.  The  pain,  and  discharge  of  matter 
and  blood,  were  rapidly  bringing  on  true  cancerous  cachexia.  I 
heard  from  him  occasionally  till  his  death,  which  took  place  a 
few  weeks  after  I  saw  him.  I  heard  that  the  autopsy  showed 
large  cancerous  masses  developed  in  the  pelvis,  and  in  some  of 
the  internal  organs,  but  I  got  no  authentic  report  of  the  ap- 
pearances. 

Mr.  Stanley  considers  the  disease  as  a  local  malady,  and  I 
am  not  prepared  to  deny  that  it  is  so  in  some  cases.  He  does 
not  give,  however,  the  after-history  of  any  of  his  patients,  but 
I  think  there  is  good  ground  for  believing  that  the  malignant 
history  of  my  case  was  repeated  in  at  least  some  of  his. 

Dr.  Delafield  gives  me  the  following  account  of  a  knee-joint, 
which  was  the  seat  of  a  large  tumor  which  had  been  growing 


368  MALIGNANT  DISEASES  OF  BONE. 

for  some  years,  the  knee  having  been  in  a  condition  of  disease 
for  about  sixteen  years.  The  limb  was  removed  by  Dr.  James 
E..  "Wood.  "The  articulating  extremities  of  the  femur  and. 
tibia,  the  patella,  and  the  soft  tissues  around  the  joint,  are 
softened,  ulcerated,  and  partly  replaced  by  new  tissue.  There 
are  several  fistulous  openings  into  the  joint.  The  new  tissue 
consists  of  cells  of  various  size  and  shape,  mostly  of  an  epithe- 
lial character.  Hound  and  polygonal  nucleated  cells,  and  large, 
flat,  pavement  epithelial  cells  predominate."  StachelzeUen  "  are 
also  found  in  considerable  numbers.  The  characteristic  mark  of 
the  tissue  is  the  nests  of  epithelial  cells  packed  together.  The 
cancroid  structure  is  most  complete  in  the  tissue  replacing  the 
bone,  least  so  in  the  tendons.  In  the  latter  are  found  portions 
consisting  of  round  granulation-cells." 


CHAPTEK  IV. 

MELAKOID   CA3TCEK   Df   BOXE. 

PATHOLOGISTS  are  hardly  yet  agreed  as  to  whether  this  form 
of  cancer  can  lay  claim  to  any  other  anatomical  peculiarity  than 
the  existence  of  the  black  pigment  through  the  structures  of 
which  it  is  composed.  Mr.  Paget  is  very  emphatic  on  this  point. 
He  says :  "I  have  not  seen  or  read  of  any  example  of  melano- 
sis,  or  melanotic  tumor  in  the  human  subject,  which  might  not 
be  regarded  as  a  medullary  cancer  with  black  pigment.  In  the 
horse  and  dog,  I  believe,  black  tumors  occur  which  have  no 
cancerous  character;  but  none  such  are  recorded  in  human 
pathology."  In  the  main,  this  view  prevails  with  the  best 
writers  on  the  subject,  who  generally  agree  that  melanotic 
tumors  are,  in  the  human  subject,  medullary  cancers  into  which 
the  melanotic  material  has  been  introduced,  without  in  any 
other  way  altering  the  anatomical  features  of  the  structures  in 
which  it  is  found.  It  exists  mainly  in  the  shape  of  black  or 
brown  granules  which  are  sometimes  found  in  the  cells,  some- 
times in  the  nucleus,  and,  often  enough,  entirely  independent 
of  cells  or  fibres,  merely  disseminated  through  the  intercellular 


MELAXOID  CANCER  IN  BONE.  359 

substance  of  the  tissue.  In  this  distribution  it  is  extremely 
irregular,  sometimes  affecting  single  cells,  and  not  their  neigh- 
bors, generally  more  abundant  in  some  cells  than  in  others, 
often  found  plentifully  infiltrated  through  one  lobule,  while 
those  around  it  may  be  of  a  natural  color,  sometimes  all  in  the 
cells,  and  sometimes  mainly  outside  of  them,  and  not  unfre- 
quently  affecting  one  or  more  tumors  in  a  very  marked  degree, 
while  several  others  may  be  entirely  free  from  it.  What  the 
source  of  the  black  material  may  be,  whether  it  be  essential 
black  pigment,  like  that  of  the  choroid  or  lungs,  or  whether  it  be 
altered  hematoidin,  is  not  by  any  means  positively  ascertained, 
but  this  much  is  certain,  that  in  the  eye  and  in  the  integuments 
it  is  more  common  than  in  regions  which  naturally  contain  no 
pigment,  or  but  small  quantities  of  it.  The  disease  itself  is  one 
of  the  rarer  forms  of  cancer.  Mr.  Paget  gives  a  table  in  which 
he  found,  out  of  365  cases  of  cancer  of  all  kinds,  25  were  of 
the  melanoid  variety;  of  these  14  were  in  the  skin,  9  in  the 
eye  and  orbit,  1  in  the  testicle,  and  1  in  the  vagina.  He  alludes 
to  none  in  the  bones. 

In  the  bones  it  is  mostly  found  as  a  secondary  deposit,  and 
in  this  respect  the  disease  shows  one  feature  which  may  be  said 
to  be,  at  least  in  its  extent,  peculiar.  I  mean  the  very  remark- 
able disposition  it  has  to  generalization ;  so  marked  that  in  some 
instances  no  tissue — almost  no  organ,  and  scarcely  a  single  bone 
in  the  whole  body — can  be  found  which  does  not  show  some 
trace  of  the  black  deposit.  And  here  a  question  suggests  itself, 
whether,  with  all  this  constitutional  propensity  to  the  formation 
and  deposit  of  the  melanotic  substance,  it  may  not  sometimes 
be  found  accumulated  in  the  healthy  tissues  independent  of  any 
cancerous  formation  whatever.  This  question  I  cannot  answer, 
but,  from  analogy  in  the  inferior  animals,  from  the  extremely 
general  and  abundant  manner  in  which  it  is  often  distributed 
over  all  parts  of  the  human  body,  and  from  the  absence  of  all 
appearance  of  any  other  change,  as  far  as  the  naked  eye  can 
discern,  of  many  of  the  spots,  as  seen  particularly  in  the  can- 
cellous  structure  of  bone,  I  am  disposed  to  expect  that  the 
microscope  will  show  us  that  these  secondary  black-pigment  in- 
filtrations are  sometimes  projected  into  tissues  otherwise  per- 
fectly normal,  and  entirely  independent  of  any  cancerous  forma- 
24 


370  MALIGNANT   DISEASES   OF   BONE. 

tion.  These  views  were  suggested  to  me,  and,  I  think,  con- 
firmed to  a  great  extent,  by  the  observation  of  the  following 
case,  which,  perhaps,  will  aiford  us  a  study  of  the  most  impor- 
tant clinical  features  of  melanoid  disease  : 

Peter  Ries,  aged  thirty-three  years,  applied  at  the  German 
Dispensary  of  this  city,  April  27,  1869,  on  account  of  several 
black  tumors  on  different  parts  of  the  surface  of  his  body.  The 
patient  stated  that  he  had  had,  from  his  earliest  childhood,  a 
pigmentary  nsevus  of  the  size  of  a  small  bean,  situated  over  the 
angle  of  the  left  scapula,  which,  without  any  known  cause,  be- 
gan to  grow  larger  about  two  months  before,  and  had  then 
attained  the  size  of  an  egg.  The  first  melanotic  tumors  devel- 
oped in  the  immediate  vicinity  of  this  mole.  From  the  first  day 
when  he  applied  for  treatment,  up  to  the  very  last  day  of  his 
being  under  observation  (a  period  of  about  eight  months),  not  a 
day  passed  without  new  tumors  being  discovered,  either  on  the 
surface  of  the  body  or  inside  of  the  cavities  of  the  mouth,  larynx, 
or  ear.  From  close  observation  of  hundreds  of  these  melanotic 
tumors  of  the  skin,  Dr.  Simrock,  under  whose  care  the  patient 
was  during  almost  the  entire  course  of  the  disease,  states  that 
they  all  took  their  origin  from  the  subcutaneous  tissue,  and  en- 
croached upon  the  cutis  only  after  they  had  attained  a  certain 
size,  until  finally  they  reached  the  surface  of  the  skin,  by  thin- 
ning its  elements  by  pressure  from  below.  As  soon  as  the 
growths  reached  the  surface,  they  began  to  undergo  marked 
retrogressive  metamorphosis,  and,  shrivelling  up  and  decaying, 
they  gradually  disappeared,  and  left  only  a  black  mark  as  indi- 
cating their  former  presence.  In  some  cases  even  this  last  dark 
pigmentary  discoloration  was  observed  to  fade  away,  leaving 
the  skin  only  of  a  somewhat  darker  hue  than  in  the  surround- 
ing parts. 

In  some  instances  the  surface  of  the  tumors  became  ulcer- 
ated, and  a  scab  formed  over  them  which  finally  desquamated, 
leaving  only  a  discolored  surface  beneath.  A  few  tumors  were 
observed,  which  showed  no  pigmentation.  About  two  months 
after  he  first  came  under  observation,  he  began  to  complain  of 
his  eyesight,  and  especially  of  soreness  of  the  left  eye,  when 
the  existence  of  a  melanotic  tumor  of  the  size  of  a  large  pin's- 
head  was  detected  in  the  inner  and  upper  half  of  the  iris.  In 


MELANOID  CANCER  IN  BONE.  371 

a  very  short  time — about  fourteen  days — the  iritic  tumor  devel- 
oped to  its  utmost  size,  about  the  diameter  of  a  large  pea,  and 
then,  in  about  the  same  length  of  time,  it  ran  through  its  retro- 
gressive course,  until  finally  only  some  extremely  slight  discol- 
oration of  the  aifected  spot  could  be  observed.  Vision  was  at 
first  slightly  interfered  with,  but,  upon  the  subsidence  of  the 
tumor,  it  became  normal.  •  A  similar  growth  appeared  in  the 
right  eye,  with  much  more  severe  impairment  of  vision. 

The  patient's  general  condition  underwent  no  marked 
change  for  the  worse,  until  some  large  tumors  developed  in 
the  tongue,  the  painful  condition  of  which  materially  interfered 
with  mastication  and  deglutition,  and  this  began  to  tell  upon  his 
nutrition.  Up  to  the  latter  half  of  October  the  man  continued 
to  work  at  his  trade,  and  had  not  lost  a  single  day.  About  that 
time  he  had  a  slight  attack  of  varioloid,  from  which  he  recov- 
ered without  any  untoward  symptom,  but  he  steadily  failed  in 
strength  afterward.  One  of  the  melanotic  tumors,  on  the  right 
side  of  the  tongue  near  its  root,  was  very  deeply  ulcerated,  and 
so  painful  that  it  was  difficult  for  him  to  swallow.  The  surface 
of  the  body  was  covered  with  innumerable  black  tumors,  vary- 
ing in  size  from  that  of  a  small  shot  to  that  of  a  hickory-nut. 
He  continued  to  fail  in  strength,  and  died,  exhausted,  January 
13,  18TO. 

Dr.  Simrock  says  :  "  The  diagnosis  of  the  character  of  all 
these  metastatic  tumors  was  based  upon  the  microscopical  ex- 
amination of  the  primary  one,  and  of  several  others  which  were 
taken  out  for  the  purpose.  The  primary  tumor  from  the  back 
proved  to  be  true  sarcoma,  in  the  formation  of  which  the  fusi- 
form and  round  cells  equally  participated.  Pigmentary  parti- 
cles I  was  not  able  to  see  in  any  of  the  sarcomatous  cells.  The 
pigmentary  part  of  the  tumor  was  entirely  intercellular,  and 
appeared  in  the  form  of  irregularly-shaped  particles  and  cakes 
of  different  tinges,  from  blood  red  to  deep  black,  in  the  forma- 
tion of  which  the  extravasated  and  stagnated  blood  may  have 
had  its  part.  One  small  tumor,  the  size  of  a  bean,  was  extir- 
pated from  the  inner  side  of  the  left  humerus,  and  showed  the 
same  sarcomatous  elements  as  the  primary  one,  with  pigmen- 
tary interspersion  as  the  chief  characteristic  part  of  its  constitu- 
ents. Five  particles  were  removed  from  tumors  which  after- 


372 


MALIGNANT   DISEASES   OF   BONE. 


ward  disappeared  almost  entirely,  leaving  only  a  discoloration 
of  the  skin,  and  in  both  the  same  characteristic  elements  of 

sarcoma  were  undoubtedly  preva- 
lent. If  late  microscopical  exami- 
nations corroborate  my  diagnosis 
of  true  sarcoma,  then  its  sponta- 
neous disappearance  will  prove  a 
precious  experience  to  the  pathol- 
ogist. Yirchow  remarks,  in  his 
book  on  tumors,  that  '  up  to  this 
time  he  knows  of  no  well-proved 
case  of  sarcoma  having  spontane- 
ously disappeared. ' 

"  On  post-mortem  examination, 
black  tumors  were  found  here  and 
there  on  the  membranes,  and  in 
the  substance  of  the  brain.  The 
pleurae,  both  parietal  and  visceral, 
and  also  the  pericardium,  were 
studded  with  small  black  masses. 
External  surface  of  heart  covered 
with  pigment-spots,  some  project- 
ing, others  not.  In  the  substance 
of  the  heart,  the  pigment  seemed 
to  follow  the  course  of  the  mus- 
cular fibres.  The  columnse  car- 
ne93,  as  well  as  all  the  internal 
surface  of  the  organ,  were  mottled 
with  similar  masses.  Both  lungs 
were  infiltrated  with  pigment-mat- 
ter throughout.  Mucous  surface 
of  larger  bronchial  tubes  contain- 
ing spots  of  pigment.  Bronchial 
glands  enlarged  and  black.  The 
diaphragm  contained  melnnotic 
tumors  on  both  surfaces  and  in 
its  substance,  as  did  also  the  peri- 
tonaeum, both  visceral  and  parie- 
tal, the  omentum,  the  stomach,  the  intestines,  large  and  small, 


FIG.  103.— (Museum,  College  of  Physi- 
cians and  Surgeons.) 


COLLOID   CANCER   OF  BONE.  373 

the  pancreas,  the  mesenteric  glands,  the  liver,  the  spleen,  the 
kidneys,  the  urethral  mucous  surface,  the  bladder,  the  prostate, 
the  corpora  cavernosa,  the  testicles,  and  the  cord.  The  muscles 
everywhere  were  infiltrated  with  the  same  black  pigment,  which 
followed  in  a  marked  manner  the  course  of  the  muscular  fibres." 
Dr.  Delafield  made  a  careful  examination  of  many  of  the  locali- 
ties mentioned,  and  his  observations  are  of  much  interest.  In 
all  the  situations  where  distinct  tumors  existed,  the  pigmentary 
matter  was  contained  either  in  round  or  oval  cells,  or  in  their 
intercellular  substance,  in  granules  fine  and  coarse,  or  infiltrated 
into  the  neighboring  tissues,  thus  forming,  as  it  were,  the  out- 
skirts or  borders  of  the  sarcomatous  nodule.  In  several  situa- 
tions, however,  it  was  distinctly  made  out  that  the  deposit  had 
taken  place  in  the  substance  of,  and  in  the  interstices  between, 
the  elements  of  perfectly  normal  and  unchanged  original  tis- 
sue. This  was  particularly  the  case  in  the  bronchial  mucous 
membrane,  in  the  kidneys,  in  some  parts  of  the  skin,  and  in  a 
portion  of  the  fibrous  structure  of  the  dura  mater.  These  ob- 
servations were  made  with  much  care ;  and  in  reference  to  this 
very  point,  as  to  whether,  in  the  human  subject,  pigmentary 
accumulations  ever  take  place  independent  of  cancerous  disease, 
in  any  of  the  situations  where  pigment  is  not  normally  found. 
They  seem  to  me  quite  conclusive. 

Several  of  the  bones  were  marked  by  black  spots,  and  when 
sawed  through  the  cancellous  tissue  presented  numerous  black 
dots,  and  irregularly-shaped  spots,  due  to  the  infiltration  of  the 
melanoid  matter  into  tissue  otherwise  perfectly  healthy.  Fig. 
103  represents  a  section  of  the  lower  portion  of  the  femur, 
which  exhibits  quite  a  number  of  the  peculiar  black  spots. 


CHAPTER  Y. 

COLLOID    CANCER    OF    BONE. 


THAT  form  of  cancerous  disease  which  is  characterized  by 
numerous  alveoli,  containing  a  glue-like  material,  is  occasionally 
seen  in  the  bones.  Mr.  Stanley  gives  a  very  well-marked  ex- 
ample, occurring  in  the  phalangeal  bone  of  a  finger.  The  case 


374  MALIGNANT   DISEASES   OF  BONE. 

was  under  the  care  of  Mr.  Lawrence,  in  St.  Bartholomew's 
Hospital.  "  A  man,  sixty-five  years  old,  had  been  healthy  from 
birth,  and  both  his  parents  had  been  healthy  and  long-lived. 
Rather  more  than  a  year  ago,  he  noticed  a  swelling  in  the  first 
phalanx  of  the  right  fore-finger ;  it  was  moderately  firm,  gave 
him  little  pain,  but  gradually  increased.  Six  months  ago  a 
lancet  was  thrust  into  it,  and  some  blood,  with  a  watery  fluid, 
was  discharged,  and  ulceration  of  the  opening  ensued.  A  seton 
was  afterward  passed  through  the  swelling,  and  immediately 
afterward  it  rapidly  increased.  The  hand  was  amputated  at 
the  wrist-joint,  and,  in  the  examination  of  the  diseased  parts, 
the  following  particulars  were  observed :  The  tumor  was  of  a 
globular  form,  soft  and  elastic,  and  about  two  inches  and  a  half 
in  diameter.  It  enveloped  the  first,  with  part  of  the  second 
phalanx  of  the  fore-finger ;  its  interior  consisted  of  a  semifluid, 
jelly-like  substance,  contained  within  cells  formed  by  dense, 
white,  fibrous  bands.  The  tumor  closely  surrounded  the  bone, 
which  was  rough  in  one  situation,  while,  in  another,  part  of  its 
wall  had  disappeared.  Within  the  bone,  gelatinous  substance 
was  deposited,  like  that  of  which  the  tumor  consisted.  Mr. 
Paget  submitted  this  substance  to  microscopic  examination,  and 
found  that  it  possessed  none  of  the  characters  of  cartilage,  but 
apparently  consisted  of  a  structureless,  viscid  jelly."  He  also 
remarks  that  there  is  in  the  museum  of  St.  Bartholomew's  Hos- 
pital an  example  of  this  same  form  of  tumor  growing  from  a  rib. 
In  the  museum  of  the  New  York  Hospital  there  is  a  cast 
(No.  47)  of  the  head  of  a  patient  with  a  huge  tumor,  involving 
one  side  of  the  face,  which  is  stated  to  have  sprung  apparently 
from  the  antrum,  and  to  have  extended  from  that  point  in  all 
directions,  so  as  to  fill  the  mouth  and  pharynx,  pressing  upward 
into  the  orbit,  and  causing  absorption  of  the  septum  narium, 
extending  up  through  the  sphenoid  bone  to  the  base  of  the 
brain,  and  forming  externally  a  large  tumor  upon  the  lateral 
and  lower  parts  of  the  left  side  of  the  face  (Fig.  104).  The 
tumor  was  surrounded  by  an  imperfect  capsule,  and  consisted 
chiefly  of  cells  filled  with  an  amber-colored  gelatinous  fluid. 
The  bones  upon  the  outer  parts  of  the  growth  were  softened, 
and  very  much  thinned  by  pressure,  but  did  not  seem  to  be  in- 
filtrated with  any  foreign  material.  The  brain  was  not  involved. 


COLLOID  CANCER  OF  BONE.  375 

The  patient  was  a  man  thirty-five  years  old,  who  had  long  suf- 
fered from  symptoms  resembling  those  of  ozsena,  but  the  tu- 
mor was  not  discovered  in  the  fauces  until  within  a  year  of  his 
death,  which  took  place  chiefly  from  exhaustion,  from  continued 
ptyalism,  and  inability  to  swallow  food. 


FIG.  104.— (N.  T.  Hospital  Museum.) 

Dr.  Louis  Bauer  laid  before  the  New  York  Pathological 
Society,  at  its  meeting  in  January,  1857,  a  tumor  of  the  size  of 
a  man's  fist,  which  he  had  removed  from  the  surface  of  the  left 
femur  just  behind  the  great  trochanter,  which  presented  all  the 
appearances^of  colloid  disease.  The  tumor  had  been  growing 
about  two  years.  At  one  time,  an  abscess  had  formed,  dis- 
charging a  viscid  substance  with  the  pus.  He  had  suffered 
much  pain,  and  was  greatly  reduced  by  the  disease.  About  six 
months  previous  to  the  time  of  presenting  the  specimen,  Dr. 
Bauer  had  removed  the  tumor.  After  the  portion  presented 
had  been  taken  away,  the  femur  was  found  to  be  extensively 
carious.  All  diseased  bone,  as  far  as  could  be  reached,  was 
gouged  oif,  but  the  whole  of  the  tumor  could  not  be  got  away. 
The  wound  healed,  however,  and,  at  the  time  of  reporting,  the 
man  remained  well. 

Lebert  gives  the  history  of  a  case  which  was  under  the  care 


376  MALIGNANT  DISEASES  OF  BONE. 

of  Roux  in  1846.  A  man,  aged  thirty-eight,  had  two  moderate- 
sized  tumors  of  the  upper  end  of  the  tibia,  one  on  either  side 
of  the  knee-joint.  They  had  been  growing  about  three  months 
without  pain,  and  followed  a  strain.  There  was  no  heat  nor  red- 
ness about  them,  and  no  other  feeling  but  a  growing  weakness 
of  the  limb.  There  was  a  slight  pulsation  felt  on  laying  the 
hand  gently  over  the  surface  of .  either  swelling.  Supposing 
them  to  be  of  a  vascular  nature,  Roux  tied  the  femoral  artery. 
Secondary  haemorrhage  occurred ;  a  second  ligature  was  applied 
higher  up ;  but  the  man  died  from  pyaemia.  No  change  had 
been  produced  in  the  tumors  by  the  operation.  The  upper  part 
of  the  tibia  was  found  occupied  by  an  encephaloid  mass,  pro- 
jecting on  either  side  into  the  two  tumors  noticed  during  life. 
This  mass  contained,  in  all  parts,  numerous  gelatinous  points. 
The  bone-substance  was  displaced  by  the  tumor,  and  had  at  that 
point  entirely  disappeared.  In  the  inside  of  the  mass  the  mor- 
bid deposit  was  of  a  yellowish,  pale-rose  color.  "  By  micro- 
scopic examination,  as  well  as  by  the  naked  eye,  the  colloid 
nature  of  the  cancer  can  be  seen,  which  is  besides  very  vascular. 
There  is  everywhere  a  very  abundant  transparent  substance, 
in  which  are  a  few  fine,  rare,  divergent  fibres.  This  substance 
everywhere  contains  fusiform  cancerous  elements,  having  a 
length  of  -£$  of  a  millimetre.  Some  of  these  were  pointed,  and 
some  rounded  at  their  ends.  The  nuclei  are  round  or  elliptical, 
and  from  -fa  to  ^  of  a  millimetre  in  diameter.  Some  are  free. 
The  nucleoli  are  about  Tfir  of  a  millimetre  in  diameter.  There 
are  almost  no  fatty  elements  in  the  cancer." 

Cruveilhier  figures  a  very  beautiful  case  of  alveolar  cancer 
which  grew  in  the  bones  of  the  face  of  a  woman  who  died  of  it 
at  the  age  of  fifty-two.  It  occupied  the  ethmoid,  nasal,  and 
frontal  bones,  made  a  huge  projection  on  the  anterior  and  upper 
part  of  the  face,  and  encroached  back  into  the  fauces,  filling  up 
the  nasal  cavities,  and  pressing  backward  upon  the  brain.  It 
had  grown  slowly  for  about  ten  years,  with  great  pain,  though 
the  patient,  who  was  a  painter  of  some  merit,  had  continued  at 
her  work  almost  to  the  end.  On  section,  the  whole  mass  pre- 
sented the  peculiar  alveolar  arrangement  which  characterizes 
colloid.  The  alveoli  were  large,  and,  though  of  different  size, 
were  nearly  uniform  in  every  part  of  the  tumor.  The  peculi- 


OSTOID  CANCER. 


arity  of  the  case  was,  that  these  alveoli,  instead  of  being  filled 
with  a  transparent,  jelly-like  material,  contained  a  whitish-yellow 
substance,  which  Cruveilhier,  in  one  place,  likens  to  concrete 
pus,  and  in  another  speaks  of  as  consisting  of  caseum.  No  can- 
cerous disease  was  found  in  any  other  part  of  the  body. 

These  cases  all  are  instances  of  the  primary  form  of  the  col- 
loid disease,  and  of  this  they  present  a  tolerable  picture.  From 
what  we  know  of  the  tendency  to  generalization  of  this  disease 
in  the  softer  parts  of  the  body,  we  can  well  suppose  that  it  may 
sometimes  appear  as  a  secondary  deposit  in  the  bones  ;  I  think, 
however,  it  must  in  this  form  be  rather  rare.  I  have  never 
seen  an  instance,  nor  have  I  encountered  any  statement  of  one, 
in  any  of  the  authors  whose  works  I  have  had  an  opportunity 
of  consulting. 


CHAPTER  YI. 

OSTOID   CANCER. 

SEVERAL  writers  have  insisted  upon  giving  this  name  to  a 
form  of  cancer  containing  a  very  large  proportionate  amount 
of  bone ;  and  yet  in  other  parts  and  in  other  respects  present- 
ing all  the  characteristics  of  true  cancer.  These  ostoid  cancers 
are  found  most  often  in  the  lower  end  of  the  femur,  and  most 
commonly  affect  equally  the  inside  and  the  outside  of  the 
bone.  The  softer  parts  of  the  growth  do  not  exactly  correspond 
either  with  the  scirrhous  or  encephaloid  material.  Mr.  Paget 
describes  the  substance  as  "  usually  exceedingly  dense,  firm,  and 
tough,  and  may  be  incompressibly  hard ;  its  cut  surface  uprises 
like  that  of  an  intervertebral  cartilage,  or  that  of  one  of  the 
toughest  fibrous  tumors  of  the  uterus.  It  is  pale  grayish,  or 
with  a  slight  yellow  or  pink  tint,  marked  with  irregular  short 
bars  of  a  clearer  white  ;  rarely  intersected  as  if  lobed,  but  some- 
times appearing  banded  with  fibres  set  vertically  on  the  bone." 

The  bony  portion  of  the  mass  is  still  more  peculiar.  He 
says  :  "  In  the  central  parts  it  is,  in  the  best-marked  specimens, 
extremely  compact,  scarcely  showing  even  any  pores,  white  and 
dry.  To  cut  it  is  nearly  as  hard  as  ivory,  yet,  like  hard  chalk, 


378 


MALIGNANT   DISEASES   OF   BOXE. 


it  may  be  rubbed  or  scraped  into  fine  dry  powder.  At  the 
periphery  it  is  arranged  in  a  knobbed  and  tuberous  form,  the 
knobs  being  often  formed  of  close,  thin,  gray,  or  white  lamellae, 

whose  presenting  edges  give  them  a 
fibrous  look,  exactly  like  that  of 
pumice-stone.  In  this  part,  also,  the 
bone  is  very  brittle,  flaky,  and  pul- 
verulent. In  some  specimens,  the 
whole  of  the  bone  has  this  delicate 
lamellar  and  brittle  texture ;  but,  more 
generally,  as  I  have  said,  the  central 
part  is  very  hard,  and  this,  occupying 
the  walls  and  cancellous  tissue  of  the 
shaft,  equally  with  the  surrounding 
part  of  the  tumor,  makes  of  the  whole 
such  a  compact,  white,  chalky  mass  as 
the  sketch  here  represents."  Fig.  105 
is  the  picture  Mr.  Paget  gives  of  the 
disease  thus  described. 

"Whatever  may  be  thought  of  the 
expediency  of  erecting  this  form  of 
disease  into  a  separate  class  of  can- 
cers, its  well-marked  features  evi- 
dently entitle  it  to  a  position  as  an 
important  variety.  It  has  already 
been  remarked  that,  with  most  of  the  cancers  of  bone,  the 
osseous  tissue  is  displaced  by  the  cancerous  growth,  and  that 
very  little  and  often  no  new  growth  of  bone  accompanies  the 
destruction  of  the  old  bone-substance,  at  the  expense  of  which 
the  morbid  growth  is  constantly  increasing.  Even  in  those 
cases  where  something  like  a  bony  skeleton  is  formed  in  the 
cancerous  mass,  this  skeleton  is  usually  composed  of  exceed- 
ingly slender  spicula,  and  thin  and  delicate  laminae,  which  hold 
a  very  small  proportion  to  the  whole  mass,  and  which  are  usu- 
ally so  imperfect  in  their  construction,  and  so  fragile  in  their 
consistence,  that,  when  macerated  and  dried,  it  is  exceedingly 
difficult  to  preserve  them  from  falling  to  pieces  almost  by  their 
own  weight.  To  all  this  a  very  strong  contrast  is  presented 
by  the  tumors  now  under  consideration,  whose  most  striking 


FIG.  105.— (From  Paget.) 


OSTOID   CANCER.  379 

feature  is  a  very  great  deposit  of  new  bone  as  a  basis  of  the 
growth — a  deposit  which  seems  to  be  a  constant  accompaniment 
of  that  growth,  and  to  increase  paripassu  with  its  increase,  so 
that,  in  some  of  the  largest  tumors  of  this  kind  which  have  been 
described,  the  proportion  of  bone  in  the  growth  was  quite  as 
great  as  in  the  smallest. 

Another  feature,  equally  striking  and  equally  important  as 
clearly  marking  the  true  cancerous  character  of  the  disease,  is 
found  in  the  tendency  to  generalization  which  these  tumors  so 
markedly  display,  in  which  the  most  distant  and  most  unex- 
pected organs  are  sometimes  implicated.  The  secondary  de- 
posits preserve  the  character  of  the  original  growth,  and  hence 
we  have  the  lymphatic  glands,  the  uterus,  the  blood-vessels,  and 
even  the  thoracic  duct,  filled  up  or  infiltrated  with  bony  sub- 
stance so  completely  as  in  some  instances  to  become  unrecog- 
nizable. 

Mr.  Stanley  gives  three  cases  of  this  disease  which  he  terms 
malignant  osseous  tumor  of  bone :  "  A  man,  aged  thirty,  was 
admitted  into  St.  Bartholomew's  Hospital  under  the  care  of 
Mr.  Lawrence,  with  a  swollen  and  painful  state  of  the  right 
knee-joint,  consequent  on  a  fall,  for  the  removal  of  which  anti- 
phlogistic treatment  was  successfully  employed ;  but,  shortly 
afterward,  a  painful  swelling  arose  immediately  above  the  knee, 
and  gradually  extended  around  the  lower  third  of  the  thigh. 
A  softening  of  the  swelling  at  one  point  being  discovered,  an 
incision  was  made  into  it,  from  which  arterial  blood  flowed 
freely.  Pulsation  was  now  discovered  in  the  swelling,  and  at 
the  same  time  it  was  observed  that  the  leg  had  become  redema- 
tous,  and  that  the  toes  were  colder  than  in  the  opposite  limb. 
The  femoral  artery  was  then  tied.  Pulsation  in  the  tumor 
ceased,  and  its  size  gradually  diminished ;  but  after  some  time 
it  again  enlarged,  sloughing  of  the  skin  and  central  substance 
of  the  tumor  ensued,  but  unaccompanied  by  haemorrhage.  The 
man  gradually  sank  from  exhaustion. 

"  On  examining  the  limb,  I  found  the  tumor  to  consist  of  a 
compound,  soft,  fibrous,  and  dense  osseous  substance,  the  latter 
extending  completely  round  the  femur.  The  whole  series  of 
femoral,  inguinal,  and  lumbar  absorbent  glands,  were  converted 
into  osseous  tumors.  The  femoral  and  popliteal  vessels  were 


380  MALIGNANT  DISEASES   OF  BONE. 

sound.  In  this  case  the  tumor  of  the  femur,  and  the  tumors 
of  the  absorbent  glands,  were  identical  in  structure,  both  being 
composed  almost  wholly  of  a  solid,  dull-white,  chalk-like,  osse- 
ous substance,  which,  in  the  femur,  was  continuous  with  a  sim- 
ilar deposit  in  the  medullary  and  cancellous  tissue  of  all  that 
part  of  the  bone  which  was  surrounded  by  the  tumor." 

As  a  general  rule,  this  form  of  cancer  is  rapid  in  its  prog- 
ress, and  Mr.  Paget  reckons  them  about  equal  to  the  medullary 
in  the  length  of  life  they  allow  to  the  patient.  Some  cases  are 
spoken  of  in  which  life  was  prolonged  for  many  years.  Thus, 
Mr.  Stanley  mentions  one  where  the  disease  was  in  progress  for 
eighteen  years.  Mr.  Paget  'alludes  to  two  cases  where  death 
did  not  occur  until  in  one  instance  twenty-four,  and  in  another 
twenty-five  years,  had  elapsed  from  the  time  of  the  first  appear- 
ance of  the  affection.  On  the  other  hand,  some  cases  are  re- 
corded in  which  the  disease  has  run  a  course  as  rapidly  destruc- 
tive as  the  most  rapid  medullary  cancers.  Mr.  Paget  gives  one 
case  of  this  rapid  progress  of  ostoid  cancer  in  a  girl  of  fifteen, 
who  was  admitted  into  St.  Bartholomew's  Hospital  "  with  gen- 
eral feebleness  and  pains  in  her  limbs,  which  had  existed  for 
two  or  three  weeks.  They  had  been  ascribed  to  delayed  men- 
struation, till  the  pain,  becoming  more  severe,  seemed  to  be 
concentrated  about  the  lower  part  of  the  back  and  the  left  hip. 
A  hard,  deep-seated  tumor  was  now  felt,  connected  with  the  ala 
of  the  left  ilium.  This  gradually  increased,  with  constant  and 
more  wearing  pain ;  it  extended  toward  the  pelvic  and  abdomi- 
nal cavities ;  the  patient  became  rapidly  weaker  and  thinner ; 
the  left  leg  swelled  ;  sloughing  ensued  over  the  right  hip;  and 
she  died,  cachetic  and  exhausted,  only  three  and  a  half  months 
from  her  first  notice  of  the  swelling. 

"  A  hard,  lobulated  mass  was  found,  completely  filling  the 
cavity  of  the  pelvis,  and  extending  across  the  lower  part  of  the 
abdominal  cavity.  It  was  firmly  connected  with  the  sacrum, 
both  ischia,  and  the  left  ilium  ;  it  held,  as  in  one  mass,  all  the 
pelvic  organs ;  and  the  uterus  was  so  embedded  in  it,  and  so  in- 
filtrated with  a  similar  material,  that  it  could  scarcely  be  recog- 
nized. The  general  surface  of  this  growth  was  unequal  and 
nodular.  It  was  composed  of  a  pearly -white  and  exceedingly 
hard  structure,  in  which  points  of  yellow  bony  substance  were 


TREATMENT  OF  MALIGNANT   DISEASE   OF  BONE.  331 

embedded,  and  which  had  the  characters  of  ostoid  cancer  per- 
fectly marked.  The  ilium,  where  the  tumor  was  connected 
with  it,  had  the  same  half-fibrous,  half-bony  structure  as  the 
tumor  itself.  The  common  iliac  veins,  their  main  divisions, 
and  others  leading  into  them,  passed  through  the  tumor,  and 
were  all  distended  with  hard  substance  like  the  mass  around 
them.  From  the  common  iliac  veins,  a  continuous  growth  of 
the  same  substance  extended  into  the  inferior  cava,  which,  for 
nearly  five  inches,  was  distended  and  completely  obstructed  by 
a  cylindrical  mass  of  similar  fibrous  and  osseous  substance  one 
and  a  quarter  inch  in  diameter.  At  the  upper  part  this  mass, 
tapering,  came  to  an  end  near  the  liver.  The  lower  lobe  of  the 
right  lung  was  hollowed  out  into  a  large  sac,  containing  green- 
ish pus,  and  traversed  by  hard,  coral-like  bands,  which  proved 
to  be  branches  of  the  pulmonary  artery  plugged  with  firm  white 
substance,  intermingled  with  softer  cancerous  matter,  and  re- 
sembling the  great  mass  of  disease  in  the  pelvis.  The  rest  of 
the  lung  was  healthy,  with  the  exception  of  some  scattered 
grayish  tubercles ;  and  so  was  the  left  lung,  except  in  that  there 
were  a  few  small  abscesses  near  its  surface,  with  hard,  bone-like 
masses  in  their  centres,  like  those  in  the  branches  of  the  right 
pulmonary  artery.  The  skull,  brain,  pericardium,  heart,  and 
all  the  abdominal  organs,  were  healthy." 

In  the  other  aspects  of  its  general  pathology,  the  ostoid  can- 
cer differs  in  no  material  respect  from  other  forms,  except  per- 
haps in  the  fact  that  it  shows  no  particular  tendency,  under 
ordinary  circumstances,  toward  ulceration,  or  any  other  form 
of  rapid  destruction.  It  is  acknowledged,  however,  by  those 
who  have  best  studied  the  disease,  that  materials  for  the  full 
story  of  its  life  and  terminations  have  as  yet  hardly  been  accu- 
mulated. 


CHAPTEK  YH. 

TREATMENT   OF   MALIGNANT  DISEASE   OF   BONE. 

THE  cancerous  tumors,  of  bone  present,  as  a  matter  of  course, 
nothing  more  encouraging,  as  far  as  their  treatment  is  con- 
cerned, than  cancerous  tumors  in  other  parts.  A  large  share 


382  MALIGNANT  DISEASES  OF  BONE. 

of  the  success  which  some  of  the  older  surgeons  claimed  as  the 
result  of  their  several  methods  of  treatment  we  can  now  ex- 
plain, with  great  plausibility,  by  their  want  of  accurate  diagno- 
sis ;  while  the  few  instances  in  which  the  cure  is  unequivocal, 
we  are  disposed  to  refer  to  the  coincidence  of  a  spontaneous 
or  natural  retrogression,  rather  than  to  the  result  of  the  reme- 
dies employed.  It  is  somewhat  disheartening  to  find  that,  as 
our  knowledge  of  these  growths  advances,  our  conviction  of 
their  utterly  intractable  nature  grows  deeper ;  and  that  surgeons 
of  the  present  day,  with  all  their  increased  light,  and  with  their 
greatly-improved  means  of  diagnosis,  are  less  sanguine  and  less 
confident,  as  to  the  therapeutics  of  cancer,  than  were  the  men 
of  half  a  century  ago.  The  hopes  which  have  been  excited  by 
the  various  remedies  lauded  as  curative  of  cancer  have  one  by 
one  been  sadly  disappointed,  the  expectations  roused  by  the 
vaunted  powers  of  compression,  electricity,  caustic  fleches,  gal- 
vano-cautery,  acetic  acid,  etc.,  have  sobered  down  to  the  simple 
question,  not  whether  these  remedies  are  curative,  but  whether 
they  are  in  any  degree  beneficial  to  the  sufferer.  Indeed,  I  think 
it  would  not  be  too  much  to  say  that,  in  the  minds  of  the  best 
men  who  are  now  occupying  themselves  with  this  study,  the 
question  of  cure  has  very  much  given  place  to 'the  question  of 
palliation ;  and  that  the  labors  and  hopes  of  such  men  centre 
more  upon  alleviating  suffering,  and  prolonging  comfortable 
life,  than  Ihey  do  upon  Utopian  projects  for  the  fundamental 
cure  of  the  disease.  Much  may  be  done  short  of  a  cure,  for 
the  great  benefit  of  our  cancerous  patients,  and  it  seems  very 
clear  to  me  that  it  is  in  this  direction  that  our  therapeutical 
labors  are  likely  to  be  most  fruitful,  and  our  efforts  on  behalf 
of  our  patients  most  beneficial. 

I  am  far  from  wishing  to  undervalue  or  to  deny  the  useful- 
ness of  certain  internal  remedies,  from  some  of  which  I  think 
I  have  myself  derived  benefit.  Indeed,  I  consider  the  subject 
is  worthy  of  our  most  serious  attention. 

The  most  recent  statements  I  have  seen  on  this  subject  are 
those  of  Mr.  T.  Weeden  Cooke,  whose  long  experience  as  sur- 
geon of  the  Cancer  Hospital  in  London  gives  great  weight  to 
his  opinion.  In  his  work  on  "  Cancer,  and  its  Allies  and  Coun- 
terfeits," he  devotes  much  space  to  the  subject  of  treatment, 


TREATMENT   OF  MALIGNANT  DISEASE   OF  BONE.  383 

and  passes  in  review  the  various  internal  remedies  which  have 
been  most  used  in  the  hope  of  curing  cancer.  His  verdict  upon 
all  of  them  is  unsparing  and  decisive.  He  has  found  no  benefit 
from  their  use  which  is  worth  naming,  and  he  dismisses  them 
all  as  unworthy  of  confidence,  as  having  any  specific  influence 
on  the  course  or  termination  of  the  disease.  Nevertheless,  he 
is  one  of  the  most  hopeful  and  encouraging  of  modern  writers 
on  the  treatment  of  cancer.  Viewing  the  disease  as  one  in 
which  the  perverted  cell-growth  depends  upon  want  of  tone  in 
the  system,  and  believing  that  this  tone  can,  in  a  certain  degree, 
be  imparted  by  appropriate  treatment,  he  asserts  most  confi- 
dently that,  by  the  judicious  use  of  certain  nutritive  tonics, 
with  proper  local  applications,  much  may  be  done  in  arresting 
the  progress,  relieving  the  suffering,  and  actually  curing  the 
disease.  The  internal  remedies  which  he  relies  upon  with  most 
confidence  are  cod-liver  oil,  iron,  hydrochloric  acid,  and  cin- 
chona-bark. The  first  two  are  the  principal  remedies  he  em- 
ploys, the  latter  auxiliaries,  to  which  he  sometimes  adds  other 
tonics  according  to  the  condition  of  the  digestive  and  nervous 
systems.  Of  the  oil  he  says :  "  There  is  only  one  other  medi- 
cine which  has  any  large  claim  upon  our  attention,  either  as  an 
assistant  and  rectifier  of  the  digestive  process,  or  as  a  direct 
alterative  and  tonic  to  the  blood.  In  my  hands  cod-liver  oil, 
administered  in  the  occult  stage  of  a  scirrhus  of  the  breast,  has 
more  nearly  approached  the  character  of  a  specific  than  any 
other  agent.  It  seems  to  supply  that  aliment  to  the  cells  of 
new  formations,  for  the  want  of  which  they  droop  from  their 
rotund  form,  and  lose  the  power  of  creating  normal  tissues." 
The  results  of  his  treatment  are  encouraging  and  surprising, 
for  he  gives  an  outline  of  fifteen  cases  in  which  manifest  benefit 
was  derived  from  the  course  adopted,  of  which  cases,  all  under 
his  personal  observation,  he  says :  "  These  are  a  few  instances 
of  arrest  of  scirrhus  of  the  mamma  by  constitutional  means, 
for  ten,  twelve,  even  sixteen  years,  and  the  patients  are  still 
living  evidences  of  the  conservative  powers  of  Nature,  when 
properly  supported  by  art,  to  stem  the  destructive  influences  of 
this  malignant  disease,  and  reduce  it  to  a  mere  inert  mass." 

It  will,  however,  be  more  in  accordance  with  my  plan  to 
glance  at  a  few  of  the  local  remedies,  which  have  gained  most 


384  MALIGNANT  DISEASES  OF  BONE. 

favor  with  the  profession,  as  favorably  modifying  the  progress 
and  result  of  cancer  developed  in  the  bones.  Of  these,  five 
are  of  chief  interest :  1 .  Repeated  local  depletion  by  leeches ; 
2.  Systematic  compression ;  3.  Galvano-electricity ;  4.  Ligature 
of  artery  leading  to  tumor ;  5.  Ablation. 

1.  Repeated  Local  Depletion  ty  Leeches. — This  method  of 
treating  cancer  is  one  of  the  oldest  known.  In  former  times, 
when  almost  every  swelling  was  regarded  as  a  modified  form 
of  inflammation,  the  idea  very  naturally  suggested  itself  to 
treat  the  cancerous  form  of  inflammation  by  local  abstraction 
of  blood.  Something  was  found  to  be  gained  by  this  practice, 
and  it  has  maintained  its  popularity  perhaps  more  steadily 
down  to  the  present  day  than  any  other  remedy  on  the  list. 
The  explanation  of  its  good  effects,  according  to  our  present 
view,  must  be  based  upon  its  influence  in  abating  local  conges- 
tions, and  accidental  inflammations  in  the  tumor,  to  which  local 
actions  modern  pathology  ascribes  a  certain  considerable  share 
in  the  destructive  agencies  which  are  at  work  in  any  cancerous 
growth.  That  any  thing  can  be  gained  in  modifying  what  may 
be  called  the  normal  nutritive  processes  of  such  a  tumor,  by  a 
remedy  which,  like  leeching,  can  only  have  an  occasional  appli- 
cation, does  not  seem  to  be  likely ;  but  that,  by  relieving  fulness, 
and  averting  or  curing  inflammation,  it  may  do  good  in  diseases 
where  the  worst  influences  in  operation  are  acknowledged  to 
be  those  of  the  inflammatory  character,  is,  it  seems  to  me,  a 
reasonable  expectation.  On  this  point  "VYalshe,  after  alluding 
to  the  long  -  continued  popularity  of  the  treatment,  says: 
"  Modern  experience  has  established  the  degree  of  utility  of 
local  abstraction  of  blood.  In  the  earliest  stages  of  diseased 
induration  the  application  of  leeches  is  strongly  advisable ;  even 
as  a  guide  to  the  diagnosis  of  tumors  of  a  doubtful  character, 
it  is  useful.  The  progress  of  growth  of  undoubtedly  carcinoma- 
tous  nature  may  be  thus  retarded,  and  incidental  inflammatory 
symptoms  in  the  adjoining  tissues  successfully  combated ;  but 
beyond  this  capillary  depletion  has  no  power.  The  number  of 
leeches  applied  must  be  regulated  by  the  size  of  the  tumor ;  it 
should  vary  between  twelve  and  six ;  a  smaller  number  causes 
an  aiflux  of  fluids  to  the  part  without  emptying  the  vessels 
sufliciently.  AVhen  the  tumor  is  adherent  to  the  skin,  there  is 


TREATMENT   OF  MALTCIXANT   DISEASE   OF  BONE.  335 

danger  in  continuing  the  practice,  as  the  bites  have  frequently 
been  known  to  pass  into  persistent  ulcerations." 

Whatever  may  be  the  decision  of  a  more  rigorous  statistical 
inquiry  into  the  retarding  influence  of  occasional  leechings, 
there  can  be  no  doubt  that  in  certain  instances  they  do  accom- 
plish some  good  by  the  relief  of  pain.  Much  of  the  suffering 
inflicted  by  these  dreadful  diseases  is  caused  by  or  aggravated 
by  accidental  inflammations,  which  are  under  the  control  of 
well-regulated  local  depletion ;  and,  it  is  a  wonderful  fact, 
recognized  by  all  who  have  much  employed  the  remedy,  that 
in  some  instances  the  immunity  from  pain  procured  by  a  sin- 
gle application  of  leeches  will  last  much  longer  than  can  be  ex- 
plained by  the  relief  of  a  simple  attack  of  inflammation.  It 
would  seem  as  if  the  sedative  effect  of  loss  of  blood  sometimes 
remained  after  the  immediate  depressing  effect  had  been  appar- 
ently recovered  from,  and  the  vital  actions  of  the  affected  parts 
seem  to  be  modified  for  a  certain  indefinite  period  by  a  cause 
which  we  ordinarily  consider  to  be  of  temporary  and  generally 
of  brief  influence.  This  relief  of  pain,  and  its  accompanying 
soreness  and  tenderness,  is  an  immense  benefit  to  the  sufferers 
with  cancer ;  and  we  can  hardly  help  associating  with  the  means 
of  procuring  alleviation,  the  idea  of  at  least  a  tendency  toward 
a  cure.  The  testimony  of  many  writers  is  favorable  to  the  use 
of  this  remedy,  although  it  must  be  acknowledged  that  those 
who  have  spoken  most  eulogistically  of  its  effects  have  been 
those  who  upheld  most  earnestly  the  inflammatory  nature  of  all 
cancerous  disease. 

Much  caution  should  be  exercised  in  the  use  of  this  means, 
which  is  powerful  for  evil  if  used  too  freely.  By  too  frequent 
or  too  liberal  an  employment  of  local  depletion,  it  is  very  evi- 
dent we  may  so  reduce  the  vital  power  of  the  part  affected  as 
to  favor  rather  than  to  check  morbid  action,  and  thus,  by  weak- 
ening the  power  of  resistance,  we  may  increase  the  evil  tenden- 
cies of  the  disease  by  the  very  means  we  employ  to  relieve  it. 
Again,  as  Mr.  Stanley  remarks,  care  should  be  used  in  applying 
leeches  over  a  tumor  which  is  already  adherent  to  the  skin,  the 
leech-bites  becoming  sometimes  the  starting-point  of  ulceration, 
which  might  perhaps  have  been  long  postponed  had  th,e  skin 
remained  un wounded. 
25 


386  MALIGNANT  DISEASES  OF  BONE. 

2.  Systematic  Compression. — This  is  not  a  new  remedy  for 
cancer.  It  was  first  brought  to  notice  by  Dr.  Young  in  the 
earlier  years  of  this  century,  and  was  tried  very  fully  at  the 
Middlesex  Hospital  in  1816,  with  so  unsatisfactory  results  that 
but  little  more  was  heard  of  it  till  M.  Recamier  revived  its  use, 
and  announced  some  wonderful  successes.  Unfortunately,  the 
enthusiastic  experimenter  claimed  a  great  deal  too  much  for 
his  pet  plan,  and  accordingly  the  profession  generally  has  dis- 
credited his  results.  He  says :  "  Of  one  hundred  patients,  six- 
teen appeared  to  be  incurable,  and  underwent  only  a  palliative 
treatment ;  thirty  were  completely  cured  by  compression  alone, 
and  twenty-one  derived  considerable  benefit  from  it ;  fifteen 
were  cured  by  extirpation  alone,  or  chiefly  by  extirpation  and 
pressure  combined,  and  six  by  compression  and  cauterization ; 
in  the  twelve  remaining  cases,  the  disease  resisted  all  the  means 
employed."  Even  the  high  character  of  M.  Recamier  can 
hardly  give  currency  to  such  magnificent  statements,  and  yet 
something  must  have  been  realized  by  the  treatment  to  have 
formed  a  basis  for  such  exaggerated  praise.  What  this  some- 
thing was,  we  can  glean  from  the  reports  of  other,  perhaps  more 
candid,  experimenters  with  the  same  method. 

In  the  year  1859,  my  late  venerable  and  esteemed  friend  Dr. 
J.  P.  Batchelder  published,  in  the  New  York  Journal  of  Medi- 
cine, an  account  of  his  experience  in  the  treatment  of  various 
affections  by  pressure  applied  by  compressed  sponge.  Among 
other  things,  he  had  tried  the  effect  of  the  remedy  in  a  number 
of  cases  of  cancerous  and  other  morbid  growths,  and  the  results 
he  obtained  are  well  worthy  of  attention.  No  one  who  knew 
him  could  doubt  the  truthfulness  of  his  statements,  certainly  not 
the  honesty  of  his  convictions.  His  explanation  of  the  modus 
operandi  of  his  plan  he  thus  states :  "  The  pressure  occasioned 
by  the  expansion  of  the  compressed  sponge  disturbs  the  cancer- 
cells,  and  forces  them  out  of  place ;  affects  their  consistency,  and 
causes  them  to  be  dissolved ;  and  the  tumor,  thus  freed  of  its 
malignant  ingredients,  may  be  more  readily  removed  by  absorp- 
tion, if  the  process  be  continued,  or,  if  not  absolutely  removed, 
it  may  be  so  divested  of  its  malignity  as  to  remain  harmless  for 
years,  as  happened  in  a  case  which  will  be  related.  Does  this 
pressure,  as  the  doctrine  teaches,  deprive  the  cancer-cells  of  their 


TREATMENT   OF  MALIGNANT  DISEASE   OF   BONE.  337 

power  to  contaminate  other  parts,  or  the  system  in  general  ? 
The  cancer-cell,  like  the  pus-globule,  is  dissolved,  and,  being 
thus  changed  in  its  nature,  is  more  readily  absorbed,  and  of 
course,  enters  the  circulation,  not  as  a  malignant,  but  as  an  in- 
nocuous substance ;  and,  instead  of  contaminating  the  system, 
is  eliminated  therefrom,  as  are  other  disintegrations  of  tissues 
and  structures,  without  harming  any  part.  Cancerous  affec- 
tions, locally  considered,  seem  to  derive  their  nutriment  from 
surrounding  parts  by  a  sort  of  imbibition  or  endosmosis,  and 
not  from  any  direct  vascular  medium.  The  sponge,  by  its  pecul- 
iar mode  of  pressure  on  the  diseased  part,  either  destroys  its 
texture,  or  prevents  its  being  nourished,  and  continues  to  do  so 
until  its  agency  is  fully  resisted  by  the  circumjacent  parts  which 
are  in  a  healthy  condition."  In  support  of  his  views,  he  then 
goes  on  to  relate  a  number  of  cases  in  which  great  benefit  was 
gained  by  the  use  of  the  sponge ;  in  one  of  them  the  tumor  en- 
tirely disappearing  in  less  than  two  months  from  the  commence- 
ment of  the  treatment.  Some  of  the  cases  were  treated  in  pri- 
vate practice,  and  some  in  Bellevue  Hospital,  and  all  of  them 
were  watched  more  or  less  carefully  by  some  of  our  best  sur- 
geons. I  give  the  full  history  of  one  which  is  most  to  our  pur- 
pose, inasmuch  as  the  disease  was  seated  in  a  bone  : 

"A  lad,  about  eight  or  ten  years  old,  from  New  Jersey,  was 
brought  by  his  mother  to  Dr.  Mott's  clinique,  in  184/T  or  1848, 
with  a  fungous  tumor  protruding  from  the  lower  jaw,  situated 
in  the  space  formerly  occupied  by  the  first  and  second  molar 
teeth,  on  the  left  side.  This  morbid  growth  had  made  its  ap- 
pearance some  months  before,  loosening  the  teeth,  protruding 
011  each  side  of  them,  and  pushing  away  or  involving  the  gums, 
previous  to  his  coming  to  the  clinique.  The  teeth  had  been 
extracted,  and  the  tumor,  with,  I  believe,  a  portion  of  the  alveo- 
lar process,  removed  by  a  surgeon  in  the  boy's  immediate  vicin- 
ity, which  operation  was  now  repeated  by  Dr.  Mott.  In  a  few 
weeks,  the  little  fellow  was  brought  again  to  the  clinique,  the 
disease  having  returned.  Unable  to  lay  my  hand  on  the  notes 
of  the  case,  I  have  indeed  forgotten,  as  well  as  Dr.  Mott  him- 
self, whether  another  operation  was  performed.  "Whether  it 
was,  or  was  not,  is  quite  immaterial  to  our  purpose.  The  dis- 
ease had  returned ;  and  at  my  suggestion  the  compressed  sponge 


388  MALIGNANT   DISEASES   OF  BOXE. 

was  to  be  tried ;  and  lie  was  assigned  by  Dr.  Mott  to  my  care 
and  management.  I  took  him,  with  his  mother,  to  my  office, 
and  cut  two  or  three  pieces  of  thoroughly  compressed  sponge 
sufficiently  large  to  cover  the  whole  tumor,  and  indeed  extend 
beyond  it  on  the  outer  and  inner  sides  of  the  alveolar  process, 
and  rising  higher  than  the  upper  surfaces  of  the  adjacent  teeth 
before  and  behind  it ;  and  then  bound  the  lower  maxilla  firmly 
to  the  upper  by  means  of  a  roller,  leaving  the  pieces  of  sponge 
to  expand  by  the  imbibition  of  saliva.  The  mother  was  sup- 
plied with  several  pieces  of  compressed  sponge,  and  directed  to 
apply  them  in  the  same  manner  once  or  twice  a  day.  She  was 
told  by  Dr.  Mott  that  the  disease  was  of  a  malignant  character, 
and  would  be  very  likely  to  destroy  her  son — certainly,  if  not 
properly  and  faithfully  attended  to.  The  doctor's  faith  in  a 
favorable  result  was  obviously  not  very  strong ;  nor  was  any- 
body's else,  except  my  own.  Notwithstanding,  in  the  course 
of  five  or  six  weeks  the  mother  and  lad  again  appeared  at  Dr. 
Mott' s  clinique,  not  to  ask  advice,  but  to  show  the  result,  that 
the  boy  was  perfectly  cured.  The  remedy  had  been  entirely 
successful.  The  location  of  the  disease  had  been  favorable  to 
the  application  and  action  of  the  sponge.  The  result  in  this 
case  was  analogous  to  what  I  had  witnessed  in  others." 

The  doctor  then  alludes  to  one  other  case  in  which  a  similar 
tumor,  situated  on  the  lower  jaw  of  a  lady  between  fifty  and 
sixty  years  of  age,  was  treated  by  the  compressed  sponge  with 
an  equally  perfect  result. 

The  theoretical  views  expressed  by  the  advocates  of  this 
mode  of  practice  are  ingenious,  and  not  improbable.  That  cell 
life  and  growth  may  be  modified  and  destroyed  by  pressure, 
seems  entirely  likely,  as  the  mere  result  of  the  action  of  me- 
chanical force ;  that  it  is  actually  accomplished  is  demonstrated 
by  the  cases  published.  Thus  much  is  practically  certain,  that 
tumors,  even  malignant  tumors,  can  be  entirely  removed,  un- 
der favorable  circumstances,  by  the  mere  action  of  carefully- 
regulated  pressure ;  and  this  clinical  fact  adds  just  so  much  to 
our  means  of  contending  with  cancerous  disease.  That  the 
method  has  any  power  of  modifying  the  local  cancerous  action 
on  the  surrounding  parts,  or  on  the  general  system,  is  not  only 
not  proved,  but  not  rendered  probable  by  any  of  the  facts  which 
have  as  yet  been  made  public. 


TREATMENT   OF   MALIGNANT  DISEASE   OF  BONE.  389 

3.  Galvano- Electricity. — This  agent  has  been  employed  in 
the  treatment  of  cancerous  diseases  in  two  modes  quite  dis- 
tinct from  one  another.  One  of  these  methods  is  that  in  which 
the  circuit  through  which  the  electricity  passes  is  so  arranged 
that,  at  a  certain  point,  the  conducting  material  becomes  in- 
tensely heated,  and  this  heated  portion,  being  in  contact  with 
the  point  of  disease  on  which  it  is  desired  to  act,  produces  the 
cauterizing  effect  of  intense  heat,  and  destroys  the  part  ex- 
posed to  its  influence.  This  s  is  an  exceedingly  convenient 
method  of  employing  electricity  to  produce  the  effect  of  the 
actual  cautery,  but  it  must  be  evident  that  the  action  is  simply 
that  of  a  caustic,  not,  so  far  as  appears,  specially  modified  by 
the  fact  of  electricity  having  been  used  to  produce  the  heat. 
There  is  no  breach  of  contact,  and  therefore  no  passage  of  the 
electric  fluid  through  any  part  of  the  tissues ;  and,  therefore, 
any  specific  effect  of  electricity,  as  such,  in  modifying  the  mor- 
bid actions  in  the  parts  through  which  the  conductor  passes, 
may,  I  think,  be  properly  left  out  of  consideration,  and  this 
form  of  electrical  application  may  be  considered,  as  it  is  com- 
monly named,  a  mere  galvano-cautery. 

The  other  method  is  one  in  which  the  electrical  current  is 
caused  to  pass  through  the  part  to  be  acted  upon — the  mode 
of  its  passage,  and  the  extent  of  its  action  upon  the  tissues, 
varying  very  much  according  to  the  manner  of  its  employ- 
ment. Either  the  Faradaic  or  the  direct  current  may  be  used, 
and  either  may  be  applied  externally  on  the  unbroken  skin, 
or  either  may  be  caused  to  act  upon  the  deeper  tissues  through 
needles  thrust  into  their  substance.  The  use  of  electricity  by 
external  application  is  much  the  oldest  method,  but  much  the 
least  effective  ;  indeed,  the  testimony  we  have  of  its  usefulness, 
in  the  discussion  of  tumors  of  any  kind,  is  confined  to  so  few 
well-authenticated  instances,  that  not  many  surgeons  now  em- 
ploy it.  The  method  which  has  of  late  attracted  most  attention 
is  that  in  which  the  power  of  the  current  is  so  great  that,  when 
introduced  into  the  tissues  by  properly-prepared  needles,  a  de- 
composition of  some  of  the  textural  elements  takes  place,  by 
which  such  alteration  in  the  mass  is  set  up  that  absorption  or 
alteration  of  the  tumor  is  the  immediate  or  ultimate  conse- 
quence. What  is  the  precise  extent  of  this  decomposition,  and 


390  MALIGNANT  DISEASES   OF  BONE. 

how  precisely  it  affects  the  elements  of  tlie  tissues,  are  points 
which  are  not  yet  fully  explained.  The  method  itself,  from  the 
decomposition  which  accompanies  it,  is  called  electrolysis. 

Electrolysis  has  now  been  used  in  quite  a  large  number  of 
tumors  of  all  kinds,  and  with  a  degree  of  success  which  leads 
us  to  hope  that  it  is  to  be  a  positive  addition  to  our  means  of 
dealing  with  these  intractable  and  unpromising  deformities.  I 
do  not  know  that  any  thing  has  yet  been  achieved  in  the  direc- 
tion of  controlling  the  malignant  features  of  these  diseases,  but, 
merely  speaking  of  them  as  tumors,  much  has  certainly  been 
accomplished.  I  cannot  better  present  the  main  features  of 
this  method  of  treating  tumors  than  by  giving  an  outline  of  a 
case  recorded  by  Dr.  R.  P.  Lincoln,  in  the  Medical  Record  of 
this  city,  for  December  15,  1870 : 

A  gentleman,  aged  thirty-three,  was  the  subject  of  a  soft 
tumor  in  the  supra-clavicular  space  of  the  left  side.  It  had 
appeared,  without  known  cause,  about  eighteen  months  before, 
and  with  slight  interruptions  had  pretty  steadily  increased  up 
to  the  time  of  his  coming  under  Dr.  Lincoln's  care.  The  tu- 
mor was  now  the  size  of  a  large  goose's-egg,  moved  to  a  certain 
degree  with  the  trachea,  was  rounded  in  shape,  two  inches  in 
diameter,  and  rising  about  five-eighths  of  an  inch  from  the 
natural  surface  of  the  neck.  The  tumor  was  soft  and  compres- 
sible, but  elastic,  and  when  pressure  was  removed  resumed  its 
usual  shape.  There  was  no  pulsation,  but  it  grew  turgid  when 
the  breath  was  held,  or  any  straining  effort  made.  Under  ex- 
citement, as  from  public  speaking,  this  turgid  condition  of  the 
tumor  would  become  constant,  and  was  sometimes  attended 
with  very  alarming  symptoms  of  suffocation.  The  diagnosis 
was  venous  erectile  tumor,  and  electrolysis  was  applied,  Sep- 
tember 30,  1870. 

"  The  patient  having  been  chloroformizecl,  I  introduced  four 
gilded  steel  needles,  insulated  to  one-half  or  three-fourths  of  an 
inch  from  their  points,  into  the  four  quarters  of  the  tumor,  the 
two  upper  being  one  and  one-fourth  inch  apart,  and  one  inch 
above  the  lower,  which  were  one  inch  apart.  The  two  inner 
needles  were  connected  with  the  subdivided  anode,  and  the 
outer  two  with  the  subdivided  cathode,  and  ten  elements  of  the 
battery,  which  was  working  with  a  weak  current,  connected 


TREATMENT   OF  MALIGNANT   DISEASE   OF   BONE.  391 

witliin  a  few  moments,  and  gradually  the  power  of  the  battery 
was  increased  to  its  maximum,  and  the  number  of  elements  in- 
creased to  fifteen.  At  the  expiration  of  fifteen  minutes,  the 
two  lower  needles  were  disengaged  from  the  current,  thus  con- 
centrating the  whole  force  upon  the  two  upper  ;  at  the  expira- 
tion of  fifteen  minutes  more,  the  needles  were  removed.  Dur- 
ing the  operation  all  the  prominences  of  the  tumor  disappeared, 
and  a  delicate  examination  detected  a  hard  mass  in  its  place. 
Not  a  drop  of  blood  escaped  on  the  removal  of  the  needles. 
The  skin  over  the  tumor  presented  a  bright  flush,  and  the  tra- 
chea had  returned  toward  its  normal  position. 

"  October  Wth. — Patient  presented  himself  for  examination. 
There  was  no  tendency  to  a  reappearance  of  the  tumor ;  on  the 
contrary,  the  induration  in  the  neck  was  steadily  diminishing 
in  size. 

"  October  22d. — The  following  is  an  extract  from  a  letter 
from  the  p'atient,  who  had  already  made  several  public  address- 
es :'  I  am  feeling  very  well,  and  there  is  nothing  to  indicate 
any  thing  like  a  recurrence  of  my  malady.' ': 

It  is  true  that  this  case  is  probably  one  of  an  erectile  tumor, 
and  as  such  would  be  likely  to  be  more  easily  affected  by  such 
local  action  as  that  of  intense  decomposing  electricity  than 
almost  any  other  form  of  growth.  It  is  nevertheless  a  fact  of 
great  interest  as  it  stands  on  the  record,  and  perhaps  will  be 
more  encouraging  when  we  reflect  how  large  a  portion  of  tu- 
mors, and  particularly  of  malignant  tumors,  are  made  up  of  a 
very  abundant  reticulation  of  vessels. 

But  electrolysis  has  been  tried  on  malignant  tumors.  Alt- 
haus,  Von  Bruns,  and  Gherini,  have  used  it  each  in  a  number 
of  cases.  Althaus  reports  that  he  has  gained  some  advantages 
in  the  treatment  both  of  scirrhus  and  encephaloid,  and  particu- 
larly speaks  of  the  relief  which  he  has  obtained  from  the  severe 
lancinating  pains  which  are  so  distressing  a  feature  of  many 
cases  of  cancer.  Yon  Bruns  is  not  so  sanguine,  and  says  that 
electrolysis  rarely,  if  ever,  disperses  or  even  materially  dimin- 
ishes a  malignant  tumor. 

The  most  surprising  case  on  record,  however,  is  one  pub- 
lished by  Dr.  William  B.  Neftel,  of  this  city,  in  the  Medical 
Record  of  September  1,  1869.  It  is  substantially  as  follows : 


392  MALIGNANT  DISEASES  OF  BOXE. 

A  gentleman,  fifty-eight  years  old,  had  a  tumor  of  the  left 
mamma,  which  by  several  good  surgeons  was  pronounced  can- 
cerous. It  was  successfully  removed  by  the  knife,  and  the 
wound  healed  favorably.  The  axillary  glands  of  that  side 
began  to  enlarge  soon  after  the  healing  of  the  wound,  and 
formed  a  large  tumor  which  also  was  successfully  removed. 
This  wound  healed  slowly,  and  upon  its  cicatrix  a  new  tumor 
grew,  which  soon  attained  the  size  of  an  orange.  The  general 
system  had  by  this  time  become  seriously  impaired.  To  this 
third  tumor  electrolysis  was  applied  by  Dr.  Neftel,  at  three 
sittings,  on  the  27th  of  April,  and  on  the  4th  and  7th  of  May, 
1869.  He  used  the  "large  apparatus  of  Kriiger  and  Hirsch- 
mann,  with  elements  of  Siemens,  subdividing,  at  the  second 
and  third  operation,  the  cathode  into  three  or  four  branches, 
connected  with  the  needles  by  serres-fines.  The  latest  improve- 
ments of  the  apparatus  afforded  the  possibility  of  gradually 
increasing  the  quantity  of  the  current  without  interrupting  the 
circuit,  and  of  diminishing  it  in  the  same  way,  so  that  the  cir- 
cuit was  broken  only  by  the  extraction  of  the  last  needle.  Not 
a  drop  of  blood  escaped.  The  first  operation  lasted  two  min- 
utes, using  ten  elements ;  the  second  five  minutes,  with  twenty 
elements;  and  the  third  ten  minutes,  with  thirty  elements. 
After  the  operation  the  tumor  increased  considerably  in  size, 
but  became  softer  and  more  elastic.  ~No  febrile  or  other  local 
or  constitutional  symptoms  followed.  On  the  contrary,  the 
patient,  who  before  was  weak,  anaemic,  and  cachectic,  began  to 
gain  flesh  and  strength,  the  tumor  at  the  same  time  diminishing 
slowly  but  constantly.  A  month  after  the  first  sitting  the 
tumor  was  found  a  great  deal  softer  and  smaller ;  at  the  end 
of  the  second  month  it  had  almost  disappeared,  and  a  fortnight 
later  no  trace  of  it  remained.  The  general  condition  of  the 
patient  is  now  in  all  respects  excellent,  and  new  deposits  can 
nowhere  be  detected.  In  his  last  letter  he  writes  to  me  as  fol- 
lows: 'I  am  not  able  to  discover  any  new  deposits  anywhere, 
nor  would  the  tumor  in  the  right  breast  be  detected  by  any 
ordinary  observer.' "  A  year  and  a  half  after  this  date  Dr. 
Neftel  reports  this  gentleman  as  doing  well. 

It  is  of  course  unsatisfactory,  certainly  unwise,  to  attempt 
to  generalize  from  a  single  case  like  the  above.  We  must  wait 


TREATMENT   OF  MALIGNANT  DISEASE  OF  BONE.  393 

for  more  light.  When  we  remember  the  natural  tendency  to 
retrogression  of  some  cancers — a  tendency  which,  under  im- 
proved general  and  local  management,  has  been  certainly  very 
much  more  prominently  recognized  during  the  last  few  years ; 
when  we  recollect  that  under  all  reasonable  modes  of  treatment 
some  cases  have  appeared  to  be  benefited;  and  when,  still 
further,  we  make  allowance  for  the  natural  disposition  for  all 
men  to  believe  what  they  wish  to  be  true — we  shall,  I  think,  be 
disposed  to  receive  these  confident  and  sanguine  statements 
with  some  grains  of  hesitation,  and,  instead  of  accepting  them 
as  decisive  of  any  therapeutical  result,  we  shall  be  disposed  to 
lay  them  away  for  future  comparison  with  other  facts  which  are 
yet  to  be  accumulated ;  satisfied  with  the  encouraging  hope  that 
they  are  pointing  us  in  the  right  direction. 

4.  Ligature  of  Arteries. — In  a  previous  chapter  some  allu- 
sion has  been  made  to  the  cutting  off  the  vascular  supply  as  a 
means  of  modifying  the  growth  of  certain  very  vascular  or 
erectile  benign  tumors.  The  same  idea  has  been  applied  to 
malignant  growths,  and  particularly  those  in  which  great  vascu- 
larity  of  the  tumor  is  a  prominent  feature.  The  idea  of  starving 
malignant  tumors  by  cutting  off  their  circulation  has  been  a 
popular  one  with  surgeons,  and  confideut  hopes  have  been  en- 
tertained that  it  would  prove  to  be  a  valuable  resource.  Theo- 
retically it  has  some  considerable  plausibility.  Though  all 
pathologists  recognize  a  certain  independent  life,  and  indepen- 
dent function  in  all  forms  of  cell,  yet  it  is  equally  recognized 
that  the  continuance  of  this  life,  and  the  perfection  of  the  func- 
tion, depend  directly  upon  the  supply  of  appropriate  material 
from  the  blood.  The  absolute  stoppage  of  this  supply  involves 
death,  the  diminution  of  it  certainly  modifies  activity:  why 
may  not  this  diminution,  carried  to  a  point  extreme,  but  not 
fatal  to  the  tissue  involved,  act  so  as  to  change  the  morbid 
actions,  either  by  stopping  them  altogether,  or  reducing  them 
within  the  limits  of  health  ?  For  the  answer  to  this  question 
we  must  of  course  turn  to  experience ;  and  I  think  I  may  say 
that  experience  is  ready  with  an  answer — probably  not  a  final 
and  decisive  answer,  but  one  which  I  think  will  enable  us,  in 
some  good  degree,  to  appreciate  the  true  value  of  the  remedy 
proposed. 


394  MALIGNANT   DISEASES  OF  BONE. 

The  advocates  of  the  operation  claim  for  it  three  distinct 
points  of  benefit  to  the  patients :  1.  A  relief  of  pain ;  2.  An 
arrest  of  progress ;  3.  A  perfect  cure.  Of  the  first  point,  that 
of  relief  from  pain,  the  claim  seems  to  be  pretty  well  sustained; 
a  very  large  majority  of  all  the  cases  operated  on  expressing 
themselves  very  greatly  benefited,  as  far  as  relief  from  suffer- 
ing is  concerned.  With  regard  to  the  second  point,  that  of 
arrest  of  progress,  it  must  be  borne  in  mind  that  we  have  here 
a  problem  much  more  uncertain  in  its  elements  than  the  mere 
existence  or  non-existence  of  pain.  What  the  rate  of  progress 
was  before  operation,  and  what  it  would  have  been  if  no  opera- 
tion had  been  performed,  are  questions  which  we  cannot  answer 
with  precision  ;  and  hence  it  comes  that  we  are  very  liable  to 
be  deceived  in  our  estimate  of  what  has  been  accomplished  by 
the  ligature  in  diminishing  a  rate  of  progress,  which  rate  we 
have  not  the  means  of  very  accurately  determining.  Still,'  good 
observers  have,  in  so  many  instances,  felt  warranted  in  record- 
ing such  arrest  of  growth  as  one  of  the  common  results  of  the 
application  of  a  ligature,  that  we  are  constrained  to  accept  it  as 
a  fact.  Of  the  third  point — a  perfect  cure — the  record  is  of 
course  by  no  means  promising.  I  must  here,  however,  explain 
what  is  meant  by  perfect  cure,  as  used  in  this  connection.  Cer- 
tainly it  does  not  mean  that  a  perfect  removal  of  local  cancerous 
growth  has  been  followed  by  an  evident  eradication  of  cancer- 
ous diathesis,  and  a  restoration  of  the  patient  to  perfect  sound- 
ness, both  local  and  constitutional.  Indeed,  so  far  as  I  under- 
stand the  views  of  the  reporters,  it  is  not  intended  to  imply 
that  under  this  treatment  there  is  necessarily  any  better  chance 
of  escaping  secondary  tumors,  generalization,  cachexia,  and 
death,  than  in  cases  where  other  means  of  removal  are  em- 
ployed. Some  enthusiastic  admirers  of  the  ligature,  encour- 
aged by  their  theoretical  views  of  its  action,  do  evidently  try 
to  persuade  themselves  that  these  bright  hopes  are  to  be  real- 
ized in  the  cases  they  give ;  but  no  high  authorities  that  I  have 
had  access  to  claim  any  thing  more  than  a  local  cure,  leaving 
the  question  of  final  result  unsettled,  either  by  their  opinions, 
or  by  the  facts  which  they  present.  With  this  understanding, 
then,  of  the  meaning  of  the  words  we  use,  we  may  say  that,  in 
a  very  small  proportion  of  the  reported  cases,  a  perfect  cure 


TREATMENT   OF  MALIGNANT  DISEASE   OF  BONE.  395 

has  resulted.  I 'have  not  myself  been  so  fortunate  as  to  see 
one  of  these  perfect  cures,  nor,  indeed,  have  I  met  with  any 
published  case  with  full  details.  I  give  two  cases,  one  of  which 
I  saw  often  with  the  gentleman  who  reports  it,  and  the  other 
occurred  in  the  practice  of  one  of  my  friends,  though  I  am  not 
sure  that  I  ever  saw  the  patient.  These  cases  are  not  cures, 
but  will  perhaps  represent  the  average  benefit  which  results 
from  the  operation,  and  therefore  are  truer  clinical  examples 
than  if  they  were  more  perfect  in  their  results. 

Madelaine  Nichols,  aged  fifty-four,  a  married  woman,  was 
admitted  to  the  New  York  Hospital,  March  30,  1855,  under 
the  care  of  Dr.  Halsted,  with  a  large  tumor  of  the  antrum  on 
the  right  side,  the  history  of  which  she  gave  as  follows  :  "  Two 
years  ago  was  first  attacked  with  pain  in  the  upper  jaw  of 
right  side ;  the  pain  constant  and  lancinating  in  character. 
During  the  next  two  months  a  swelling  of  the  jaw  showed 
itself,  gradually  increasing,  projecting  not  only  upon  the  exter- 
nal surface,  but  also  upon  the  roof  of  the  mouth,  and  in  its 
growth  pushing  out  the  last  two  molar  teeth.  About  two 
months  before  admission,  the  tumor  having  in  the  mean  time 
greatly  increased  in  size,  it  began  to  ulcerate,  and,  since  it  has 
presented  an  open  sore,  frequent  haemorrhages  have  taken 
place.  Mastication  of  food  is  difficult,  and  deglutition  much 
embarrassed.  Since  ulceration  commenced,  the  increase  of  the 
tumor  has  been  much  more  rapid.  The  general  condition  of 
the  patient  is  pretty  good. 

"  March  3()tk. — An  attack  of  haemorrhage  came  on,  in  which 
she  lost  about  four  ounces  of  blood.  During  the  following 
night  she  lost  about  the  same  amount. 

"April  2d. — On  consultation  it  was  determined,  with  a  view 
of  arresting  temporarily  the  growth  of  the  tumor,  and  prevent- 
ing the  frequent  and  exhausting  haemorrhage,  to  ligature  the 
common  carotid  artery.  This  was  accordingly  done  by  Dr. 
Halsted,  just  below  the  point  where  the  artery  is  crossed  by  the 
omo-hyoid  muscle.  The  first  effect  of  the  operation  was  to  pro- 
duce some  giddiness,  with  dimness  of  vision  in  right  eye.  This 
made  us  feel  some  anxiety  for  the  brain  ;  but  in  a  few  days  this 
passed  away,  and,  with  the  exception  of  an  attack  of  erysipelas, 
every  thing  went  on  favorably. 


396  MALIGNANT   DISEASES   OF  BONE. 

"  April  9th. — The  wound  lias  not  healed  by  first  intention 
and  is  commencing  to  suppurate.  She  has  had  no  haemorrhage 
since  the  operation,  and  there  has  been  a  visible  decrease  in 
the  size  of  the  tumor.  Deglutition  is  more  easy. 

"  May  3d. — The  ligature  came  away  to-day.  The  tumor  is 
now  about  one-quarter  of  its  original  size."  From  this  point 
the  improvement  continued.  She  left  the  hospital  on  the  8th 
of  May,  the  tumor  continuing  to  diminish  in  size,  until  it  is 
stated  in  the  notes  to  have  almost  disappeared.  The  patient 
regained  her  general  health  and  appearance,  and  remained  well 
for  seven  months,  when  the  tumor  again  began  to  grow.  She 
died  February,  1856,  unwilling  to  submit  herself  to  any  further 
surgical  treatment. 

The  other  case  occurred  in  Bellevue  Hospital,  under  care 
of  my  friend  Dr.  Stephen  Smith. 

Alice  Griffiths,  aged  fifty-three,  a  widow,  of  good  habits, 
was  admitted  to  the  wards  of  Bellevue  on  the  13th  October, 
1856.  She  had  a  tumor  of  the  left  upper  jaw,  which  had  come 
on  about  seven  months  previously.  She  had  had  some  slough- 
ing of  this  tumor,  leaving  an  open  sore,  which  gave  great  dis- 
tress on  attempting  to  eat,  and  from  which  flowed  a  large  and 
offensive  discharge.  She  was  then  much  broken  down  from 
suffering,  and  inability  to  masticate  her  food.  She  did  not  re- 
main long  in  the  hospital  at  that  time,  but  was  readmitted 
January  23,  1857.  "  The  cheek  was  now  much  enlarged  from 
the  growth  of  the  tumor.  The  fissure  from  the  slough  had 
nearly  filled  from  new  growth.  The  tumor  now  extended 
back  along  the  mesian  line  as  far  as  the  soft  palate  (part  of 
which  had  sloughed  away),  and  both  within  and  without  the 
jaw,  from  the  second  incisor  of  the  left  side  to  the  last  molar. 
She  had  great  difficulty  in  swallowing,  owing  to  the  size  of  the 
tumor,  which  was  now  as  large  as  a  hen's-egg,  and  also  from 
the  tenderness.  There  was  a  constant  oozing  of  matter  into 
the  mouth,  rendering  her  stomach  very  irritable,  and  also  oozing 
of  blood  from  time  to  time,  on  her  attempting  to  masticate  any 
food  of  unusual  hardness.  Her  health  had  rapidly  failed  during 
the  time  she  was  out.  The  left  naris  was  so  perfectly  occluded 
that  she  was  unable  to  force  air  through  it  in  blowing. 

"April  <2Mh. — The  tumor,  instead  of  diminishing  by  the 


TREATMENT   OF  MALIGNANT  DISEASE   OF  BONE.  397 

treatment  which  had  been  adopted,  has  increased.  The  dis- 
charge into  the  mouth  and  from  the  left  naris  is  extremely 
offensive;  her  hearing  is  so  much  impaired  on  the  left  side, 
that  it  is  with  great  difficulty  that  any  conversation  can  be  had, 
or  the  patient  made  to  understand  any  thing.  There  is  ex- 
treme tenderness  in  the  roof  of  the  mouth,  and  bleeding  almost 
every  time  the  patient  attempts  to  take  any  food  of  greater  con- 
sistency than  fluids.  Her  general  health  is  rapidly  failing ;  the 
tumor  now  extends  across  the  mesian  line,  back  to  the  soft 
palate,  and  is  of  the  size  of  a  medium-sized  lemon.  The  pains 
are  of  a  lancinating  character,  and  almost  constant ;  the  integu- 
ments over  the  tumor  are  tense,  shining,  and  painful  to  the 
touch.  The  patient  is  willing  to  submit  to  any  operation  that 
will  aiford  her  even  temporary  relief  from  the  pain.  The 
haemorrhage  averages  from  one  ounce  to  two  ounces  per  day 
from  the  roof  of  the  mouth,  which  is  so  sensitive  that  the 
patient  is  unwilling  to  take  her  wine,  from  the  pain  it  pro- 
duces ;  the  erysipelatous  attacks  have  become  more  frequent ; 
the  breathing  is  so  much  interfered  with  that  the  patient  is 
obliged  to  keep  the  mouth  open  in  respiration ;  she  is  rapidly 
failing  from  repeated  losses  of  blood." 

In  this  condition  the  carotid  was  tied  by  Dr.  Smith,  April 
24,  1857,  in  the  usual  situation.  She  bore  the  operation  well. 
~No  evil  consequences  followed.  The  ligature  came  away  on 
the  20th  day,  being  the  14th  of  May. 

"  May  2Sth. — The  wound  is  almost  entirely  healed  ;  a  small 
point  remains  where  the  ligature  was  removed,  which  is  pro- 
gressing favorably.  The  tumor  remains  about  the  same  size ; 
the  integuments  are  much  paler ;  the  pain  has  almost  disap- 
peared ;  the  integuments  can  be  corrugated  without  complaint 
on  the  part  of  the  patient ;  the  hardness  still  remains ;  there 
has  been  no  haemorrhage  from  the  mouth  since  the  operation, 
except  that  mentioned  as  occurring  on  the  second  day,  and  that 
followed  the  attempt  at  vomiting.  The  breathing  is  still  inter- 
fered with ;  patient  unable  to  force  air  through  the  right  naris ; 
slight  discharge  from  the  nares  and  mouth  continues ;  she  has 
improved  in  health  and  strength  ;  the  pain  has  been  alleviated ; 
the  comfcrt  she  has  enjoyed  since  the  operation,  from  the  arrest 
of  the  disease,  and  improvement  of  the  general  health,  are  daily 
remarked  by  the  patient." 


398  MALIGNANT   DISEASES   OF  BONE. 

The  history  taken  from  the  records  of  the  hospital  goes  no 
further,  but  Dr.  Smith  has  recently  informed  me  that  this  im- 
provement lasted  only  a  few  months,  when  the  disease  again 
began  to  make  progress,  and  soon  destroyed  her  life. 

In  both  these  cases  the  arrest  of  the  disease  was  manifest, 
and  in  both  so  great  an  improvement  took  place  in  the  local 
and  general  conditions,  from  the  time  of  the  application  of 
the  ligature,  that  we  are  justified  in  regarding  the  remedy  as 
having  shown  great  power  in  modifying  and  retarding  the  pro- 
gressive development  of  the  cancerous  affection.  This  same  re- 
sult, sometimes  more  and  sometimes  less  pronounced,  is  stated 
to  have  occurred  in  quite  a  large  proportion  of  the  cases  which 
are  recorded. 

In  the  July  number  of  the  New  York  Journal  of  JSfedicins, 
for  1857,  Dr.  James  E.  "Wood  has  collected  all  the  cases  he 
could  find  of  ligature  of  the  common  carotid  artery  by  Ameri- 
can surgeons.  Of  these  cases,  seventeen  were  performed  for 
the  relief  of  cancerous  tumors,  mostly  of  the  jawbones.  Of  the 
seventeen,  four  are  stated  to  have  resulted  in  the  apparent  cure 
of  the  disease ;  ten  were  decidedly  benefited,  the  growth  of  the 
tumor  being  for  the  time  arrested ;  two  died ;  one  not  noted. 
Looking  at  the  operation  merely  as  a  palliative  procedure,  and 
it  is  only  in  this  light  that  we  have  any  warrant  for  regarding 
it,  this  certainly  is  an  exceedingly  satisfactory  exhibit.  To 
these  statements  I  might  add  the  recollections  of  Dr.  Mott,  con- 
tained in  a  letter  to  Dr.  Wood,  and  published  as  part  of  the 
paper  above  referred  to. 

Dr.  Mott  says :  "  The  conclusions  I  have  come  to  are  the 
following :  that  in  malignant  disease  of  the  nares,  antrum, 
sides  of  the  head,  posterior  fauces,  and  orbit,  the  ligature  of  the 
common  carotid  of  the  side  affected  is,  not  only  a  safe,  but 
proper  operation.  If  the  disease  is  not  arrested  by  the  tying 
of  one  carotid,  the  other  ought  also  to  be  tied,  as  soon  as  the  in- 
crease of  the  disease  is  in  the  slightest  degree  manifested.  In 
several  of  each  of  these  classes  of  cases,  I  have  operated  myself, 
and  have  seen  it  done  by  others,  and  never  without  manifest 
advantages  to  the  patient,  provided  a  recovery  from  the  opera- 
tion has  followed.  It  is  well  known  that  some  have  only  lived 
three  to  five  days  after  tying  the  first  carotid. 


TREATMENT   OF  MALIGNANT  DISEASE   OF  BONE.  399 

"  I  have  seen  a  case  lately,  a  malignant  tumor  in  the  poste- 
rior fauces,  originating  probably  from  the  periosteum  and  bodies 
of  two  or  more  of  the  cervical  vertebrae,  closing  one  side  of  the 
posterior  nares,  obliterating  the  Eustachian  tubes,  and  impeding 
deglutition,  which  was  greatly  benefited  by  tying  the  carotid 
of  that  side.  The  tumor  obviously  diminished  in  size,  and  all 
the  unpleasant  symptoms  were  assuaged.  When  he  left  for 
home,  he  promised  to  return  and  have  the  artery  on  the  other 
side  tied,  as  soon  as  there  was  a  return  of  his  suffering.  In  the 
first  case  of  this  frightful  affection,  in  which  the  artery  was  tied, 
the  tumor  actually  sloughed.  In  four  instances  of  this  disease 
which  we  had  previously  met  with,  and  in  which  the  artery  was 
not  tied,  they  all  lingered  out  a  most  painful  and  distressing 
existence. 

"  I  have  seen  and  known  more  than  one  year  elapse  before 
it  was  deemed  necessary  to  tie  the  second  artery.  During  all 
this  time  the  disease  was  not  arrested,  but  atrophy  was  going 
on  constantly ;  and,  upon  tying  this  second  artery,  the  tumor, 
though  malignant,  has  entirely  disappeared.  Two  instances  of 
this  kind  I  can  now  refer  to,  in  which  the  individuals  have  en- 
joyed good  health  for  years  without  a  vestige  of  the  disease 
remaining." 

It  may  fairly  be  deduced  from  the  above  statements,  that 
ligature  of  the  artery  leading  to  the  region  affected  by  a  cancer- 
ous growth  does,  in  a  certain  quite  large  proportion  of  cases, 
favorably  modify  that  growth  in  all  the  three  ways  claimed  by 
its  advocates.  But  the  other  side  of  the  question  is  still  to  be 
considered :  In  how  many  cases  does  the  operation  involve  the 
death  of  the  patient  ?  The  answer  to  this  question  depends 
upon  many  inquiries,  and  the  most  important,  perhaps,  are  as 
to  the  disease  for  which,  and  the  artery  on  which  the  operation 
is  performed.  By  far  the  largest  number  of  cases  have  been 
growths  about  the  jaws  and  head,  and  in  these  the  carotid  artery 
has  been  tied.  The  femoral  and  brachial  have  also  been  several 
times  operated  on  for  growths  of  the  lower  portion  of  each  ex- 
tremity. The  larger  trunks  have  very  rarely  been  subjected  to 
ligature  for  cancerous  disease.  The  question,  therefore,  might 
be  narrowed  down  to  these  three  arteries,  and  even  to  the 
carotid  alone,  for  I  think  few  surgeons  would  be  willing  to  risk 


400  MALIGNANT  DISEASES  OF  BONE. 

the  dangers  of  applying  a  ligature  to  the  great  trunks,  where 
the  expectation  can  only  be  one  of  palliation  and  temporary 
benefit.  It  is  not  easy  to  get  at  the  dangers  of  these  operations, 
as  separated  from  the  diseases  and  injuries  for  which  they  were 
performed. 

Dr.  C.  Pilz,  assistant  to  the  Physiological  Institute  of  Bres- 
lau,  has  published,  in  Langenbeck's  "  Archives  of  Clinical  Sur- 
gery "  for  1868,  a  most  elaborate  and  valuable  table  of  all  the  cases 
in  which  the  carotid  artery  was  tied  for  all  causes,  in  all  countries, 
and  by  all  surgeons.  This  wonderful  specimen  of  German  in- 
dustry and  thoroughness  contains  586  cases,  and  gives  some 
details  of  the  operation,  the  disease,  and  the  result.  Of  course, 
in  such  a  vast  table,  the  details  must  be  very  slight,  and  it 
is,  therefore,  only  general  results  which  can  be  obtained  from 
its  study.  He  gives  142  cases  in  which  the  artery  was  tied 
for  tumors  of  all  kinds,  and  of  these  he  reports  87  cures,  49 
deaths,  and  12  not  stated.  The  cases  embrace  all  forms  of 
tumors,  erectile,  malignant,  etc.,  and  it  is  evident  that  the  term 
cure  refers  only  to  recovery  from  the  operation,  and  not  at  all 
to  recovery  from  disease.  How  much  the  condition  of  disease 
had  to  do  with  death  cannot  be  educed  from  this  table ;  but  this 
very  striking  fact  appears :  that,  while  in  the  cases  where  the 
ligature  was  applied  for  haemorrhage,  for  aneurism,  for  tumors, 
the  mortality '  was  from  forty  to  fifty  per  cent.,  when  we  come 
to  operations  performed  for  epilepsy  and  for  neuralgia,  we  have 
the  surprising  statement  that,  out  of  34  operations,  in  33  the 
patient  recovered,  and  in  only  one  was  death  the  result.  Still 
further,  Dr.  Pilz  refers  to  some  tables  published  on  this  very 
point  by  Yelpeau,  of  Paris,  and  Xorris,  of  Philadelphia,  in 
which  a  better  result  still  is  given,  viz.,  eight  cases  by  Xorris, 
in  which  the  carotid  was  tied  for  the  cure  of  some  affection 
of  the  nerve  centres,  all  of  which  recovered;  and  Yelpeau, 
three  cases  and  three  recoveries.  This  statement  is  all  the 
more  remarkable  when  we  reflect  that  out  of  every  hundred 
cases  in  which  the  carotid  is  ligatured  for  haemorrhage,  for 
aneurism,  and  for  the  cure  of  tumors,  twenty-two  patients  die 
of  cerebral  symptoms,  supervening  after  the  operation,  and 
manifestly  depending  on  it  as  a  cause.  That  this  should  be 
the  testimony  of  statistics  on  so  large  a  scale,  and  collected  by 


TREATMENT   OF  MALIGNANT   DISEASE  OF  BONE.  4Q1 

three  independent  and  reliable  observers,  seems  enough  to  con- 
vince us  that  the  ligature  of  the  carotid  artery  in  itself  is  almost 
free  from  danger,  and  yet  the  statement  is  so -surprising,  and  so 
contrary  to  all  our  preconceived  notions,  that  I  am  sure  sur- 
geons will  be  slow  to  accept  it  without  qualification.  The  fact 
stands  on  the  record,  however,  and  we  are  bound  not  to  over- 
look it ;  but,  at  the  same  time,  the  careful  surgeon  will  not  be 
willing  to  act,  in  any  given  case,  as  if  he  knew  that  the  ligature 
he  was  about  to  apply  to  the  carotid  artery  could  never  be  pro- 
ductive of  injury.  The  same  statistics  that  show  that  the  liga- 
ture of  the  carotid,  in  one  class  of  cases,  is  never  followed  by 
death,  show  as  clearly  that,  in  another  class,  including  the  one 
in  which  we  are  now  specially  interested,  the  mortality  after 
ligature  is  somewhere  in  the  neighborhood  of  thirty-three  per 
cent.  It  is  but  just  to  make  one  class  of  cases  rectify  the  results 
of  the  other ;  and  to  deduce  our  practical  rules,  not  from  the  con- 
sideration of  one,  but  from  a  fair  comparison  of  both,  and  an 
honest  recognition  of  the  value  of  each.  My  own  feeling  in  the 
matter  is  that,  in  all  suitable  cases  where  the  cancerous  disease 
is  making  rapid  progress,  or  is  attended  by  excessively  painful, 
or  dangerous,  or  exhausting  complications,  the  patient  has  a 
right  to  expect  from  us  the  mitigation  of  suffering,  the  rescue 
from  immediate  danger,  and  the  hope  of  prolonged  life,  which 
we  may  with  intelligent  confidence  promise  him  as  the  proba- 
ble result  of  the  ligature  of  the  artery  from  which  the  morbid 
growth  derives  its  sustenance.  The  patient  should  be  fairly 
informed  that  death  may  be  the  effect  of  the  operation  to  which 
he  submits ;  but  it  is  our  privilege  to  say  to  him  that  he  has  a 
chance  of  a  perfect  cure,  and  a  much  better  chance  of  an  im- 
provement in  his  condition,  such  as  will  fully  warrant  the  risk 
he  runs. 

5.  Ablation. — It  can  hardly  be  appropriate  for  me  to  discuss 
in  this  place  the  general  subject  of  the  propriety  of  operation 
in  cancer.  The  views  of  surgeons  on  this  point  are  gradually 
assuming  so  much  of  positiveness  in  the  light  of  recent  studies, 
both  in  diagnosis  and  in  the  statistics  of  treatment;  we  know 
so  nearly  just  what  to  expect,  and  just  what  we  may  promise ; 
the  result  of  our  procedure  is  so  nearly  uniform  in  each  class 
of  cases — that  it  would  seem  as  if  the  canon  law  of  surgery 
26 


402  MALIGNANT  DISEASES  OF  BONE. 

might  almost  now  be  recorded  on  this  subject,  with  the  hope 
that  future  revelations  would  not  materially  affect  its  provisions. 
Certain  things  seem  to  be  definitely  ascertained  with  regard  to 
the  effect  of  removing  cancerous  tumors:  1.  Jso  degree  of 
thoroughness  or  promptitude  in  operation  will,  in  any  given 
class  of  cancers,  secure  an  immunity  from  recurrence.  This 
statement  is  one  which  most  surgeons  find  it  hard  to  accept. 
The  idea  that  cancer  is,  in  its  earliest  stages,  merely  a  local 
disease  which  begins  to  affect  the  system  only  after  it  has 
gamed  a  certain  development,  and  the  feeling  that,  if  operated 
on  at  this  period,  it  will  be  eradicated  from  the  system,  and 
that,  therefore,  the  early  extirpation  should  be  insisted  on  with 
the  hope  of  permanent  cure,  are  so  plausible,  so  much  in  analogy 
with  many  other  pathological  actions  in  our  system,  that  even 
such  men  as  Mr.  Erichsen  and  Sir  William  Fergusson,  fully 
informed  as  they  are  of  all  that  has  been  done  of  late  years  in 
giving  us  precise  information  on  this  subject,  cannot  avoid 
clinging  to  it  as  one  of  the  grounds  upon  which  they  base  their 
advice  for  early  operation.  That  nothing  is  to  be  gained  by 
early  as  compared  with  late  operations,  I  would  not  be  under- 
stood to  say.  On  the  contrary,  it  seems  quite  certain  that  the 
local  disease  is,  at  all  times,  a  centre  of  contamination,  both  to 
the  neighboring  parts  and  to  the  general  system,  a  contamina- 
tion some  of  the  effects  of  which  can  undoubtedly  be  obviated 
by  early  operation.  What  I  mean  to  assert  is,  that  there  is  no 
period  in  the  history  of  cancer  where  it  is  so  unequivocally  a 
local  disease  that  its  ablation  will  protect  the  system  against  its 
reappearance.  I  believe  this  to  be,  if  not  positively  proved  by 
the  statistics  of  Mr.  Sibley  and  Mr.  Paget,  so  fairly  fledudble- 
from  their  researches,  that  it  may  safely  be  accepted  as  a  patho- 
logical fact,  and  that  upon  it  we  may  wisely  base  our  concep- 
tions of  the  value  of  treatment. 

2.  Want  of  completeness  in  an  operation  for  cancer,  whereby 
any  portion  of  the  diseased  mass  is  left  behind,  is  injurious  in 
its  effect  upon  the  progress  of  the  disease,  usually  exciting  it  to 
a  more  rapid  growth,  and  hurrying  the  disease  more  quickly 
through  its  worst  and  most  distressing  phases  to  an  earlier 
death  than  would  have  occurred  had  it  been  left  entirely  un- 
touched. 


TREATMENT  OF  MALIGNANT  DISEASE  OF  BONE.  403 

This  proposition  is  so  clearly  demonstrated,  both  by  reason- 
ing and  experience,  that  I  think  it  will  hardly  be  denied.  Even 
in  those  recurrent  tumors  which  have  no  other  quality  of  ma- 
lignancy than  their  tendency  to  return  in  loco,  we  have  ample 
evidence  of  the  evil  effect  of  partial  or  imperfect  operations,  in 
provoking  a  more  rapid  development  of  the  disease ;  and,  in 
the  most  benign  form  of  tumor,  a  portion  of  the  growth,  left 
behind,  is  almost  sure  to  reproduce,  in  aggravated  form,  the 
original  difficulty.  The  exceptions  I  have  seen  to  this  patho- 
logical law  have  been  mainly  in  those  softish  fibrous  polypi  of 
the  uterus  where,  after  ligature,  the  stump  left  behind  shrinks 
away  and  disappears ;  and  in  one  instance  of  fatty  growth, 
where  no  line  of  demarcation  could  be  traced  between  the 
original  and  the  morbid  tissues,  the  operation  whereby  a  large 
portion,  but  evidently  not  the  whole  of  the  mass,  was  removed, 
was  followed  by  a  perfect  cure.  These  are  so  manifestly  excep- 
tional instances,  that  they  do  not  invalidate  the  general  law, 
applicable  to  all  morbid  growths  of  the  tumor  character,  and 
especially  and  emphatically  true  of  those  belonging  to  the  es- 
sentially malignant  class. 

3.  The  operation  itself  is  an  element  of  danger  to  the  life 
of  the  patient  so  important,  that  it  must  not  be  overlooked. 
It  is  extremely  difficult  to  separate  this  element  entirely  from 
the  others  which  go  to  make  up  the  problem  of  the  value  of 
life  in  these  cases,  taken  as  a  class,  and  still  more  difficult  to  es- 
timate its  value  in  studying  any  single  case  ;  but  it  is  not  diffi- 
cult to  perceive  that  death,  as  a  consequence  of  the  operation,  is 
sufficiently  common  to  modify  very  seriously  any  statistical  re- 
sults we  may  wish  to  arrive  at,  and  to  be  an  important  matter 
of  consideration  in  estimating  the  propriety  of  operation  in  any 
individual  case.  Taking,  however,  the  statistics  of  Mr.  Sibley, 
we  find  that,  of  sixty-three  operations  for  cancer  of  the  breast, 
sixty  recovered  from  the  operation,  and  three  died ;  giving  a 
mortality  of  about  five  per  cent,  due  to  the  operation  itself. 
Mr.  Paget  states  that  out  of  two  hundred  and  thirty-five  opera- 
tions which  he  collated,  without  selection,  twenty-three  died— 
a  mortality  of  ten  per  cent.,  which  he  is  willing  to  accept  as 
probably  not  too  high,  at  least  for  hospital  cases.  Of  the  op- 
erations likely  to  be  required  in  cancer  of  the  bones,  we  have 


404  MALIGNANT  DISEASES  OF  BOXE. 

extirpation  of  the  jaws  and  amputation  of  the  limbs.  The 
mortality,  after  removal  of  the  upper  jaw,  taking  Hutchinson's 
and  Esmond's  collections  together,  is,  out  of  thirty-three  cases, 
six  deaths.  The  average  mortality  of  the  larger  amputations, 
when  performed  for  disease,  is  sixteen  and  one-half  per  cent. 
These  statements,  though  not  claiming  to  present  the  danger 
of  the  operation  itself,  separated  from  the  effects  of  the  disease 
for  which  it  is  performed,  show  very  clearly  that  the  risk  to  the 
life  of  the  patient,  from  the  operation  itself,  must  enter  as  a 
large  and  a  very  important  factor  in  the  sum  of  the  considera- 
tions against  the  operation,  when  deciding  as  to  its  performance 
in  any  given  case. 

These  three  considerations :  1.  That  operation  does  not  cure, 
but  merely  palliates  ;  2.  That  incomplete  operation  hastens  the 
fatal  termination ;  3.  That  the  operation  itself  adds  largely  to 
the  dangers  of  the  condition,  seem  to  me  to  embrace  the  strong- 
est points  that  can  be  made  against  an  attempt  at  removal  of  a 
cancerous  tumor.  Let  us  look  now  at  what  should  be  said  on 
the  other  side : 

1.  A  certain  number — very  small,  it  is  true — of  those  oper- 
ated on  do  recover,  and  retain  their  health  for  such  a  number 
of  years  so  perfectly,  so  far  as  cancerous  symptoms  are  con- 
cerned, as  almost  to  entitle  them  to  be  considered  perfect  cures. 
Most  of  the  practical  writers  on  this  disease  have  noted  exam- 
ples of  this  unexpected  success.  Yelpeau  speaks  of  cases  where 
fifteen  and  twenty  years  of  health  have  followed  an  operation 
for  cancer.  Sir  Benjamin  Brodie  speaks  of  two  cases,  one  of 
thirteen  years'  and  one  of  fourteen  years'  immunity  from  the 
disease  after  extirpation.  Mr.  TTeeden  Cooke  gives  a  very  in- 
teresting case  of  scirrhous  breast  removed  sixteen  years  previous 
to  his  report,  by  Mr.  Lawrence.  It  remained  well  for  ten  years. 
The  disease  reappeared,  and  was  treated  on  two  occasions  by 
caustic,  and  three  times  afterward  by  extirpation,  one  of  the 
operations  embracing  two  enlarged  axillary  glands.  At  the  time 
of  the  report,  the  patient  was  in  good  health ;  and,  though  the 
arm  had  become  within  a  few  months  cedematous,  there  was  no 
certain  evidence  of  the  reappearance  of  the  original  disorder. 
Mr.  Cooke  says  that  he  has  met  with  four  instances  in  which, 
after  operation,  the  patients  have  remained  free  from  the  disease 


TREATMENT   OF  MALIGNANT  DISEASE   OF  BONE.  4Q5 

for  a  period  of  ten  years.  Mr.  Paget  alludes  to  a  case  where  a 
patient  died  of  cancer  of  the  pelvis,  twelve  years  after  the  re- 
moval of  a  cancerous  testicle;  and  finally,  Mr.  Baker,  in  his' 
statistical  paper,  gives  a  case  in  which  a  chimney-sweep  had  a 
soot-cancer  removed  from  his  scrotum,  and  remained  well  for 
thirty-five  years,  when  the  disease  reappeared  as  an  epithelial 
growth  on  the  finger  and  hand.  All  authorities  agree  in  con- 
sidering these  as  only  exceptions  to  a  general  law,  but  the  prac- 
tical surgeon,  in  estimating  the  chances  of  life  in  any  given  case, 
is  fairly  entitled  to  all  the  encouragement  which  can  be  derived 
from  the  knowledge  that  his  patient  may  be  one  of  the  fortu- 
nate ones  where,  by  the  operation,  life  is  prolonged  almost  in- 
definitely. 

2.  All  the  statistics  which  have  been  published  on  this  sub- 
ject go  to  show  that  some  prolongation  of  life  is  gained  by  a 
complete  extirpation  of  a  cancerous  tumor.  The  principal  Eng- 
lish writers,  who  have  given  their  attention  to  the  comparing 
of  large  numbers  of  cases  of  cancer,  are  Mr.  S.  W.  Sibley,  of 
the  Middlesex  Hospital,  London,  and  'Mr.  William  M.  Baker, 
of  St.  Bartholomew's.  These  gentlemen,  working  each  in  a 
separate  field,  have  collated  more  than  one  thousand  cases  of 
all  forms  of  cancer — Mr.  Sibley  five  hundred  and  twenty  cases, 
all  treated  in  the  Middlesex,  and  about  half  of  them  observed 
by  himself,  and  Mr.  Baker  five  hundred  cases,  all  of  which  were 
seen  and  diagnosticated  by  Mr.  Paget,  about  two-fifths  of  them 
having  occurred  in  St.  Bartholomew's  Hospital,  and  three-fifths 
in  private  practice.  These  numbers  are  sufficiently  large  to 
give  value  to  the  deductions  made  from  them,  and  they  bear 
internal  evidence  of  having  been  carefully  and  conscientiously 
studied,  besides  having  received  the  approval  and  indorsement 
of  the  highest  surgical  authorities.  Mr.  Baker's  cases  are  the 
most  valuable  to  us,  as  they  were  all  external  cancers,  or  such 
as  come  under  the  care  of  the  surgeon,  while  Mr.  Sibley's  ta- 
bles embrace  both  external  and  internal ;  the  latter,  however, 
in  a  very  small  proportion. 

Both  writers  give  special  attention  to  the  question  we  are 
now  considering,  viz.,  the  length  of  life  of  the  cancer-patient 
from  the  commencement  to  the  termination  of  the  disease,  and 
the  effect  of  extirpation  of  the  cancer  upon  the  duration  of  the 


406  MALIGXAXT   DISEASES   OF  BOXE. 

disease.  Mr,  Sibley  gives  for  tlie  average  duration  of  life 
for  scirrlious  and  medullary  cancer  32J  months,  and  of  epithe- 
lial cancer  53  months.  These  he  considers  the  average  times 
of  duration  when  no  operation  has  been  performed,  the  dis- 
ease being  allowed  to  run  its  course  without  any  surgical 
treatment  other  than  palliative.  Of  the  whole  number  there 
were  63  operations,  and  no  operation  is  admitted  into  this 
table,  or  into  Mr.  Baker's,  which  was  not  supposed  to  be  a 
complete  one.  Of  the  63  operations,  three  died  and  60  recov- 
ered from  the  effects  of  the  operation — 33  of  these  cases  were 
kept  in  view,  and  the  rest  lost  sight  of.  Of  the  33,  27  had  re- 
currence of  the  disease,  in  periods  varying  from  a  few  days  up 
to  108  months,  which  was  the  longest  period  to  which  the  local 
return  was  in  any  case  delayed ;  six  cases  remained  under  ob- 
servation, being  as  yet  free  from  the  disease,  the  time  since  the 
operation  extending  in  four  of  them  to  7,  29,  36,  and  6i  months 
respectively.  The  average  period  of  recurrence,  in  those  where 
it  was  known  to  have  reappeared,  was  about  15  months. 

Mr.  Baker's  results  are  founded  on  111  cases  in  which  opera- 
tion was  performed.  He  gives  the  average  tune  of  recurrence 
in  scirrhous  about  Itt  months,  in  medullary  7-J-  months,  in  epithe- 
lial five  months,  some  of  them  returning  in  a  few  days,  others 
being  delayed  to  42,  9±,  and  one  to  110  months.  The  very 
small  number  of  medullary  and  epithelial,  as  compared  with 
the  large  number  of  scirrhous  cases,  would  raise  the  general 
average  very  nearly  to  the  rate  given  for  scirrhous,  the  result  as 
stated  by  the  two  writers  not  differing  more  than  one  or  two 
months. 

ISTow,  comparing  the  length  of  life  from  the  beginning  to 
the  end  of  the  disease,  in  those  not  operated  on,  and  in  those 
on  whom  one  or  more  operations  had  been  performed,  Mr. 
Sibley  says:  "Taking  the  period  at  which  death  took  place 
after  the  operation,  it  is  found  to  vary  from  five  to  72  months, 
the  average  duration  of  life,  after  operation,  being  30£  months. 
It  is  thus  seen  that  the  patients  operated  on  lived  53  months, 
while  those  upon  whom  no  operation  was  performed  lived  only 
32  months,  showing  that  the  cases  operated  on  lived  21  months 
longer  than  those  left  alone."  In  this  estimate  the  three  that 
died  from  the  immediate  effects  of  the  operation  are  included. 


TREATMENT   OF  MALIGNANT  DISEASE   OF  BONE.  4Q7 

If  they  had  been  left  out,  the  average  length  of  life  in  those 
operated  on  would  have  stood  at  56£  months. 

Mr.  Baker's  results  are  not  very  different  from  Mr.  Sibley's. 
He  gives  the  average  duration  from  the  beginning  to  the  end 
of  the  disease,  for  those  not  operated  on,  as,  in  scirrhus,  43 
months,  in  medullary  cancer  20  months,  and  in  epithelial  can- 
cer 27  months ;  while,  in  those  who  have  undergone  extirpa- 
tion, the  length  of  life  is  stated  to  have  been  in  scirrhus  55|- 
months,  in  medullary  cancer  33£  months,  and  in  the  epithelial 
form  57£  months.  He  makes  the  average  length  of  life  in  all 
cases  not  operated  on  as  30  months,  in  those  operated  on  48 
months.  Mr.  Baker  still  further  shows  that  the  period  at  which 
the  operation  is  performed  makes  a  difference  in  the  result 
which  is  quite  far  from  what  was  commonly  supposed,  and  that 
late  operations  usually  give  late  recurrences,  and  a  longer  aver- 
age life  than  where  the  cancer  is  extirpated  early.  This,  how- 
ever, he  explains  by  the  fact  that  late  operations  are  usually 
upon  chronic  cancers,  which  maintain  after  operation  the  same 
slow  progress  which  characterized  them  before,  and  he  does 
not  seem  to  consider  that  his  statistical  result  militates  in  any 
way  against  the  propriety  of  an  early  operation. 

In  applying  the  results  obtained  from  these  tables  to  cancer 
of  the  bones,  we  can  only  do  so  upon  general  principles.  The 
number  of  cases  of  bone-cancer  is  so  small  that  no  reliable 
results  can  be  obtained  from  their  comparison.  It  seems  pretty 
certain,  however,  that  life  is  much  more  rapidly  destroyed  by 
primary  cancer  in  the  bones  than  by  any  other  external  or  sur- 
gical form.  Thus  Mr.  Sibley  gives  the  duration  of  life  in  cancer 
of  breast  as  32J  months,  of  the  stomach  8-J-  months,  of  the  bone 
10  months ;  and  M.  Lebert  gives  very  nearly  the  same  view  of 
their  comparatively  rapid  fatality,  though  he  places  the  duration 
of  life  in  cancer  of  breast  at  42  months,  and  in  cancer  of  the 
bones  at  27  months.  Due  allowance  being  made  for  this  more 
rapid  mortality,  there  seems  to  be  no  good  reason  why  the  gen- 
eral results,  obtained  from  the  study  of  this  large  number  of 
cases  occurring  in  the  soft  parts,  may  not  safely  be  applied  to 
the  bones.  The  sources  of  fallacy  in  such  tables  become  more 
evident  the  more  they  are  studied,  and  yet,  making  all  abate- 
ments from  their  authority  which  the  most  fastidious  may 


408  MALIGNANT  DISEASES  OF  BONE. 

require,  there  remains  enough  to  indicate  very  clearly,  if  not 
to  prove  the  fact,  that,  as  a  general  law,  operations  on  cancerous 
tumors,  if  performed  in  suitable  cases,  and  thoroughly  and  faith- 
fully done,  promise,  even  including  the  risk  to  life  of  the  opera- 
tion itself,  a  prolongation  of  life,  which,  it  is  much  to  be  hoped, 
improved  methods  of  constitutional  and  local  management,  and 
a  better  knowledge  of  the  appropriate  hygiene  of  the  cancer- 
patient,  will  very  materially  increase. 

3.  When,  after  removal,  the  disease  returns,  it  does  so,  either 
entirely  or  mainly,  in  the  internal  organs,  and  the  patients  gen- 
erally die  from  the  gradual  exhaustion  of  the  cachexia  accom- 
panying secondary  cancer,  rather  than  from   the   direct   and 
dreadful  effect  of  local  disease.     That  this  is  a  positive  advan- 
tage on  the  side  of  operation,  few  will  doubt  who  have  carried 
a  case  of  external  cancer  through  all  its  fearful  stages  of  ulcera- 
tion,  sloughing,  haemorrhage,  pain,  and  sickening  fetor,  to  the 
weary  and  distressing  end,  and  have   compared  this  dreadful 
progress  with  the  more  quiet,  more  supportable,  and  infinitely 
less  offensive  features  which  characterize  the  equally  unrelent- 
ing advances  of  cancer  of  the  lungs,  or  of  the  liver. 

In  making  the  statement  that  the  return  of  the  disease  is 
apt  to  be  in  the  internal  organs,  rather  than  in  the  original 
spot,  I  wish  to  be  understood  as  confining  the  remark  to  medul- 
lary cancer,  which  is  the  class  to  which  almost  all  the  cancers 
of  the  bone  belong.  How  it  may  be  in  other  forms  I  do  not 
know,  nor  am  I  prepared  to  support  the  point  by  statistics,  for 
I  know  of  none  which  bear  on  it  that  are  sufficiently  extensive 
to  be  reliable.  I  give  it  merely  from  the  recollections  of  my 
own  cases,  many  of  them  not  recorded,  a  few  typical  examples 
of  each  kind  having  left  a  strong  impression  on  my  memory. 
Among  the  internal  organs  I  include  the  lymphatic  glands, 
particularly  those  within  the  pelvis,  where  recurrent  cancer 
of  the  bones  of  the  lower  limbs  is  apt  to  expend  its  greatest 
force. 

4.  If  the  patient  recover  from  the  operation,  he  has  an  in- 
terval of  perfect  freedom  from  the  disease,  varying,  according 
to  the  character  of  the  case,  from  a  few  weeks  to  many  months. 
In  estimating  the  blessing  which  this  complete  respite  confers 
upon  one  who  has  been  long  a  sufferer  under  the  steady  ad- 


TREATMENT  OF  MALIGNANT  DISEASE  OF  BONE.  4Q9 

vance  of  cancerous  disease,  we  ought  to  take  into  our  account 
the  effect  on  the  mind  as  well  as  on  the  body.  This  effect  is 
one  of  elation,  of  hope,  of  confidence — a  state  of  mind  which, 
apart  from  the  happiness  which  it  confers,  must  necessarily  be 
more  favorable  as  to  the  progress  of  the  constitutional  disorder 
than  the  same  number  of  months  passed  in  the  gloom  and  anx- 
iety of  steadily  progressive  local  disease.  Few  patients,  who 
find  themselves  perfectly  well  after  the  removal  of  a  cancer,  can 
resist  the  feeling  that  they  are  permanently  well.  Their  judg- 
ment may  not  tell  them  so,  and  probably  the  most  intelligent 
of  them  would  not  be  willing  to  acknowledge  it  to  themselves, 
but  there  is  a  certain  feeling,  which  I  think  I  have  often  recog- 
nized, which  gives  as  much  comfort,  in  certain  dispositions,  as 
if  their  own  judgment  and  that  of  their  surgeon  combined  to 
assure  them  that  their  cure  was  as  certain  and  as  permanent  as 
it  would  be  after  the  removal  of  a  cystic  or  a  fatty  tumor.  Of 
these  patients  Mr.  Paget  very  justly  remarks :  "  When  they  are 
no  longer  sensible  of  their  disease,  there  are  few  cancerous 
patients  who  will  not  entertain  and  enjoy  the  hope  of  long 
immunity,  though  it  be  most  unreasonable,  and  not  encour- 
aged." 

In  connection  with  this  point,  and  in  strong  contrast,  as  far 
as  the  mental  condition  is  concerned,  let  us  remember  that  a 
refusal  to  operate  is  often  a  deadly  blow  not  only  to  the  hopes, 
but  to  the  courage  and  endurance  of  the  unfortunate  patient. 
Many  of  them  have  only  gradually  brought  their  minds  to  con- 
sider the  possibility  of  an  operation,  and  have  finally  nerved 
themselves  up  to  the  point  of  consent.  Many  perhaps  have 
come  in  this  frame  of  mind  from  a  distance,  with  much  personal 
discomfort  and  pecuniary  sacrifice,  to  consult  a  surgeon,  ready 
to  submit  to  any  thing  which  he  may  deem  necessary  for  their 
relief.  After  careful  examination  and  mature  deliberation,  the 
refusal  of  an  operation  is  to  them  the  verdict  of  the  jury,  and 
the  sentence  of  the  judge,  in  the  same  breath,  condemning 
them  to  death.  It  must  sometimes  be  our  painful  duty  to  pro- 
nounce this  fearful  doom;  the  circumstances  of  the  case,  the 
condition  of  the  disease,  may  require  us  not  only  to  discourage, 
but  absolutely  to  forbid  any  attempt  at  removal ;  but  we  should 
never  forget  that  in  so  doing  we  are  taking  away  the  last  human 


410  MALIGNANT  DISEASES   OF  BONE. 

hope,  and  leaving  our  patient  to  the  darkness  and  hopelessness 
of  despair. 

I  have  thus  laid  down,  as  fairly  and  as  candidly  as  I  am  able, 
the  considerations  upon  which  we  must  base  our  advice,  as  to 
the  propriety  of  an  operation,  in  any  given  case.  But  no  gen- 
eral application  of  these  considerations  can  be  made  in  dealing 
with  individuals ;  each  case  must  be  studied  by  itself;  and  I 
know  no  more  difficult  problems,  in  all  the  practice  of  surgery, 
than  some  of  these  cases  present ;  and  no  more  delicate  ques- 
tion than  to  decide  how  earnestly  we  may  persuade  our  patient 
to,  or  dissuade  him  from  the  operation,  which  he  either  regards 
with  terror,  or  looks  to  as  his  only  human  hope.  Nevertheless, 
as  our  knowledge  has  assumed  more  precision,  so  may  our  ad- 
vice become  more  unhesitating  and  more  positive.  Let  us  hope 
it  is  becoming  more  valuable  as  it  becomes  more  emphatic. 

Acting  upon  the  principles  we  have  now  considered,  I  would 
refuse  to  operate : 

1.  In  any  case  in  which  there  was  not  a  reasonable  certainty 
that  the  whole  of  the  diseased  tissue  could  be  removed. 

2.  In  any  case  where  there  was  clear  evidence  that  secondary 
cancer  had  taken  place.    This  requires  some  modification.    The 
mere  fact  of  internal  cancer  having  begun  to  show  itself  might 
not,  in  all  cases,  forbid  an  operation.     If  the  local  disease  pre- 
sented unusually  distressing  or  threatening  appearances,  we 
might  sometimes  be  warranted  in  relieving  the  patient,  by  oper- 
ation, of  his  immediate  sufferings  and  dangers,  though  we  might 
be  sure  that  no  prolongation  of  life  could  be  gained  by  the  oper- 
ation.    As  a  general  rule,  however,  no  operation  should  be  per- 
formed where  secondary  disease  has  already  developed  itself. 

3.  In  any  case  in  which  cancerous  cachexia  was  already  well 
marked.     It  is  to  be  presumed,  in  this  case,  that  the  general  sys- 
tem is  already  poisoned  by  the  disease,  and  that  the  powers  of 
reparation  are  materially  reduced.     If  the  removal  of  the  local 
cause  could  be  relied  on  as  a  removal  of  the  whole  disorder, 
then  we  might  hope,  as  in  other  cases  in  surgeiy,  that  the  con- 
stitutional disturbance  would  abate  on  the  removal  of  the  source 
of  irritation ;  but  this  is  not  to  be  expected  in  cancer.      The 
constitutional  impairment  is  not  the  mere  reflection  of  a  central 
irritation  with  which  all  parts  suffer,  but  it  is  the  effect,  and  at 


TREATMENT  OF  MALIGNANT  DISEASE  OF  BONE.  41 1 

the  same  time  the  sign,  of  a  change  in  the  actions  of  the  whole 
economy,  which  is  as  much  a  part  of  the  disease  as  the  ulcerated 
tumor  itself,  and  which  will  not  be  arrested  in  its  progress  by 
the  most  successful  extirpation  of  the  primary  disease. 

4.  In  any  case  where  the  operation  required  was  so  formi- 
dable in  its  extent  or  character  as  to  add  materially  to  the 
dangers  of  the  patient's  condition.     "We  would  not  hesitate  to 
amputate  a  forearm,  where  we  might  refuse  to  exarticulate  at 
the  hip-joint,  and  generally  a  trifling  and  safe  operation  would 
be  more  readily  resorted  to  by  the  surgeon  than  one  of  great 
magnitude  and  danger.     Our  hopes  of  benefit  do  not  warrant 
the  running  of  greatly  increased  risk  of  life. 

5.  Where  the  patient  was  very  old,  and  the  cancer  chronic 
in  its  course.     The  slow  progress  of  the  disease  is  likely  to  con- 
tinue if  it  is  left  alone ;  the  operation  would  be  very  likely  to 
hasten  a  fatal  termination  in  advanced  age. 

6.  Where  the  patient  was  not  a  good  subject  for  any  opera- 
tion by  reason  of  bad  habits,  excessive  fat,  great  feebleness,  or 
any  organic  disease  impairing  nutrition  or  reparative  power. 
I  think,  too,  that  unconquerable  fear  of  an  operation,  or  unrea- 
sonable dread  of  its  consequences,  should  be  a  contraindication 
not  to  be  overlooked. 

On  the  other  hand,  I  would  advise  an  operation : 

1.  In  all  cases  where  the  disease  could  be  easily  and  entirely 
removed,  and  particularly  if,  as  in  the  case  of  amputating  a  can- 
cerous bone,  I  could  be  sure  of  removing,  not  only  the  disease, 
but  the  whole  organ  affected  by  it.     This,  I  think,  is  a  very  im- 
portant practical  point ;  and  I  believe  that  the  cases  in  which 
any  other  operation  than  amputation  should  be  performed  on 
one  of  the  long  bones  affected  with  cancer  must  be  very  rare 
indeed. 

2.  Where  there  was  no  suspicion  of  any  secondary  disease 
in  any  internal  organ,  and  no  extensive  affection  of  the  lym- 
phatic glands.     The  mere  enlargement  of  a  few  of  these  glands 
by  local  infection  is  no  contraindication  of  an  operation,  statis- 
tics not  showing  that  this   condition   adds  materially  to  the 
unfavorable  prognosis,  particularly  if  they  admit  of  complete 
removal. 

3.  Where  the  true  cancerous  cachexia  was  not  as  yet  devel- 


412  MALIGNANT  DISEASES  OF  BONE. 

oped  in  any  marked  degree.  It  is  not  always  possible  to  dis- 
criminate between  the  constitutional  effects  of  cancer,  as  such, 
and  those  depending  on  the  ordinary  causes  of  failing  health 
and  strength,  such  as  pain,  haemorrhage,  excessive  discharge, 
and  the  like.  In  many  cases,  however,  it  can  be  arrived  at, 
and,  where  there  seems  to  be  no  failing  of  the  powers  of  life 
but  what  can  be  accounted  for  by  the  effects  of  the  local  actions, 
we  have  a  right  to  recommend  an  operation,  in  the  hope  that, 
for  this  form  of  constitutional  impairment,  the  removal  of  the 
local  cause  will  prove  a  remedy. 

4.  If  the  operation  required  for  the  thorough  removal  of 
the  disease  be  not  one  seriously  imperilling  life.     In  cancer  of 
the  bones  this  question  is  brought  down  to  the  comparison  of  a 
very  few  operations ;  mainly,  amputations  and  excision  of  the 
upper  or  lower  jaws.     All  these  are  serious  operations,  and 
should  not  be  lightly  determined  upon  ;  but,  for  most  of  them, 
the  precise  grade  of  danger  is  almost  mathematically  proved  by 
reliable  statistics  ;  and,  inasmuch  as  in  these  operations  we  are 
cutting  through  perfectly  sound  parts,  we  may  almost  say  that 
we  can  announce  the  precise  amount  of  risk  we  are  recom- 
mending our  patient  to  assume,  in  undergoing  any  given  am- 
putation.    Of  course  this  risk  will  be  modified  by  the  condi- 
tion of  the  patient  in  other  respects  than  the  cancer  for  which 
the  operation  is  to  be  performed,  but  this  condition  presents 
nothing  which  we  are  not  accustomed  to  deal  with  in  the  ordi- 
nary problems  of  surgery,  and  is  to  be  appreciated  in  accord- 
ance with  its  well-known  laws. 

5.  If  the  cancer  be  of  slow  growth,  and  the  patient  not  old, 
we  have  very  good  reason  for  believing  that  the  recurrence  will 
be  long  delayed,  and  the  period  of  exemption  from  the  disease 
will  be  a  long,  perhaps  a  very  long  one.     It  is  from  this  class 
of  cases  that  most  of  the  so-called  cures  are  derived,  and,  though 
I  cannot  assert  that  statistics  prove  the  fact,  yet  I  think  their 
results  render  it  highly  probable,  that  the  slower  a  cancerous 
growth  is  in  passing  through  its  earlier  stages,  the  longer  is  it 
delayed  after  operation,  and  the  slower  its  progress  when  it 
does  return.     Yery  acute  cancers  are  generally  unfavorable 
cases  for  operation. 

6.  The  good  general  health  of  the  patient  is  a  strong  point 


TREATMENT  OF  MALIGNANT  DISEASE  OF  BONE.  413 

in  favor  of  an  operation,  deemed  proper  for  other  reasons,  as 
well  as  an  earnest  of  its  success.  I  cannot  help  feeling,  too, 
that  in  all  cases  a  strong  desire  for  the  operation,  ?md  strong 
conviction  that  it  will  be  successful,  on  the  part  of  the  patient, 
may  be  accepted  by  the  surgeon,  not  only  as  a  good  omen,  but, 
so  far  as  it  goes,  a  positive  indication. 

Lastly  :  though  it  may  not  flatter  our  scientific  vanity,  yet 
it  is  but  honest  to  confess  that  the  uncertainty  of  our  diagnosis 
may  give  some  encouragement  to  operation,  as,  in  removing 
what  we  believe  to  be  a  cancer,  we  may  perhaps  be  extirpating 
a  perfectly  benign  growth,  and,  instead  of  giving  our  patient  a 
brief  respite  from  death,  our  mistake  may  secure  for  him  an 
uncontaminated  and  a  healthy  life. 


INDEX. 


ABLATION  of  malignant  disease,  401. 
Abscess,  27  ;  treatment  of,  31 ;  chronic 

sinuous,  33  ;  tuberculous,  90. 
Atrophy,  16. 

Brodie,  Sir  B.,  treatment  of  abscess  of 
bone,  31. 

Cancer,  colloid,    373  ;    epithelial,    360  ; 

scirrhus,  336  ;  medullary,  340 ;  ostoid, 

377 ;  melanoid,  368. 
Caries,    94  ;    lacunal   changes   in,    100 ; 

prognosis  of,  106  ;  treatment  of,  107  ; 

passive  motion  after,  112. 
Cartilaginous  tumors,  217;   malignancy, 

221 ;  change  into  bone,  224 ;  seat  of, 

233. 
Chronic  sinuous  abscess,  33 ;  diagnosis 

of,  41 ;  treatment  of,  43. 
Cloacae,  135. 
Colloid  cancer,  373. 
Compression    In    malignant    disease   of 

bone,  386. 
Craniotabes,  59. 

Diffuse  suppuration,  45. 
Dentition  in  rickets,  69. 

Enlargement  of  bone,  24. 

Epithelial  cancer,  360  ;  secondary,  361 ; 
microscopical  characters,  361 ;  ulcera- 
tion  in,  364.' 

Epulis,  311. 

Exfoliation,  151. 

Exhaustion  from  necrosis,  150. 

Exostosis,  240 ;  intracranial,  245  ;  mul- 
tiple, 246  ;  of  fangs  of  teeth,  246  ;  can- 
cellous,  239  ;  ivory,  247. 

Exsection  of  bones,  116. 

Fibro-plastic  tumors,  276. 

Fracture  of  cervix  femoris  during  Reid's 

manipulation,  18. 
Fragilitas  ossium,  82. 


Galvano-electricity  in  malignant  disease 

of  bone,  389. 

Generalization  of  malignant  disease,  369. 
Great-toe,  exostosis  of,  228. 

Haemorrhage  in  necrosis,  150. 
Hypertrophy,  16. 

Inflammation    of    bone,    19  ;     lacunal 

changes  in,  21. 

Involucrum,  formation  of,  132. 
Ivory  exostosis,  16. 

Lacunal  changes  in  caries,  100 ;  hi  in- 
flamed bone,  21. 

Ligature  of  arteries  in  malignant  disease 
of  bone,  393 ;  in  pulsating  tumors  of 
bone,  297. 

Malacosteon,  74 ;  shape  of  pelvis  after, 
78. 

Malignant  diseases  of  bone,  335 ;  treat- 
ment of,  381. 

Medullary  cancer  of  bone,  340 ;  micro- 
scopic characters  of,  345  ;  stroma  of, 
346 ;  fluctuation  in,  350 ;  secondary, 
351. 

Melanoid  cancer  of  bone,  368  ;  generali- 
zation of,  369. 

Mercury  in  osteitis,  110. 

Mollities  ossium,  74. 

Myeloid  tumors,  276. 

Necrosis,  119;  causes  of,  121;  seat  of, 
126 ;  pathological  conditions  of,  128 ; 
sources  of  new  bone  in,  133  ;  extrusion 
of  sequestrum  in,  137  ;  symptoms  of, 
138 ;  haemorrhage  in,  143  ;  source  of 
haemorrhage  in,  145 ;  treatment  of 
haemorrhage  in,  145  ;  superficial,  152  ; 
in  heads  of  bones,  153 ;  of  short  bones, 
155  ;  of  cranial  bones,  157  ;  traumatic 
of  cranial  bones,  166 ;  treatment  of 
cranial,  166  ;  of  jawbones  from  erup- 


416 


INDEX. 


tive  fevers,  169  ;  phosphorus  necrosis, 
170 ;  reparation  after  phosphorus,  176 ; 
prognosis  of  phosphorus,  179 ;  treat- 
ment of  phosphorus,  179 ;  operations 
in  phosphorus,  182 ;  recurrence  of  phos- 
phorus, 183  ;  phosphorus  in  upper  jaw, 
183 ;  after  fractures,  184 ;  in  simple 
fracture,  186  ;  treatment  of,  after  frac- 
tures, 187  ;  fractureof  involucrum,  188; 
after  amputation,  193  ;  explanation  of, 
197  ;  without  suppuration,  200  ;  with- 
out exfoliation,  201 ;  treatment  of,  204 ; 
removal  of  sequestrum  in,  206 ;  evi- 
dences of  loosening  of  sequestrum  in, 
207  ;  operations  for  removal  of  seques- 
trum in,  208  ;  instruments  used  in  op- 
erations for,  210 ;  condition  of  bone 
after,  214. 

Ollier's  views  on  reproduction  of  bone, 
133. 

Osseous  tumors,  238. 

Osteo-myelitis,  45  ;  causes  of,  50 ;  treat- 
ment of,  51. 

Ostoid  cancer,  377. 

Pelvis  deformed  by  rickets,  63 ;  by  mala- 

costeon,  78. 

Phosphorus  necrosis,  170. 
Pulsating  tumor  of  bone,  288 ;  ligature  of 

arteries  in,  297. 

Question  of  operation  hi  malignant  dis- 
ease, 402. 

Rickets,  54 ;  symptoms  of,  55  ;  analysis 
of  bone  in,  58  ;  shape  of  pelvis  in,  63  ; 
shape  of  head  in,  66  ;  shape  of  thorax 
in,  62 ;  causes  of,  72 ;  treatment  of,  73. 

Scirrhus  of  bone,  336  ;  primary,  336 ;  sec- 
ondary, 337. 

Sedillot's  operation  for  caries,  118. 
Sequestrum,  128;  separation  of,  129. 
Sub-periosteal  resections,  117. 
Superficial  necrosis,  152. 
Suppuration  in  bone,  27  ;  diffuse,  45. 


Treatment  of  inflammation  of  bone,  26  ; 
of  abscess,  31  ;  of  osteo-myelitis,  51 ; 
of  rickets,  73  ;  of  caries,  luf  ;  of  haem- 
orrhage iu  necrosis,  145  ;  of  phosphorus 
necrosis,  179  ;  of  necrosis,  204  ;  of 
pulsating  tumors  of  bone,  297  ;  of  ma- 
lignant diseases  of  bone,  381. 

Tumors  of  bone,  215. 

cartilaginous,  217;  causes  of,  220; 

anatomy  of,  218 ;  relations  to 
malignancy,  221 ;  size  of,  222 ; 
changes  hi,  223;  softening  of, 
223. 

osseous,  238  ;  cancellous,  239 ;  seat 

of,  241 ;  ivory,  247  ;  seat  of,  249  ; 
operations  on,  253. 

fibrous,  256  ;  seat  of,  258. 

spindle-celled  fibroid,  259  ;  malig- 
nancy, 264 ;  recurrence  of,  274  ; 
duration  of,  275. 

myeloid,  276  ;  anatomical  elements 

of,  277,  282  ;  malignancy  of,  279  ; 
spontaneous  disappearance  of, 
280  ;  color  of,  282  ;  seat  of,  281 ; 
cysts  in,  286. 

pulsating,  288  ;  causes  of  pulsation 

in,  289 ;  erectile  structure  of,  291 ; 
C.  D.  Smith's  case  of,  292  ;  W. 
Parker's  case  of,  294  ;  treatment 
of,  297 ;  ligature  of  arteries  hi, 
297  ;  actual  cautery  in,  299 ;  ex- 
tirpation of,  299. 

of  the  jaws,  300  ;  inflammatory  dis- 

tention  of  antrum  in,  301 ;  cysts 
and  cystic  growths  in,  305 ;  treat- 
ment of  cysts  in,  309  ;  connected 
with  gums,  311  ;  solid,  313  ; 
fibrous,  316  ;  myeloid,  317;  ade- 
noma, 320;  treatment  of,  322; 
removal  of  upper  jaw  for,  325 ; 
removal  of  lower  jaw  for,  328 ; 
removal  of  both  upper  jaws  for, 
227. 


Upper  jaw,  phosphorus  necrosis  hi,  183; 
removal  of  both,  327. 


THE    END. 


Date  Due 


« 


CAT.    NO.    23   233  PRINTED    IN    U.S.A. 


A  ""HI  Hill 

000  499  523 


WE200 


1872 
Markoe,  Thomas  M 

A  treatise  on  diseases  of  the  bones 


CALIFORNIA  COLLEGE  OF  MEDICINE  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


at 

>-  i 


